Throughout the twentieth century, doctors, educators, social reformers, churches, the government, and the media have warned adolescents about venereal disease (VD), a group of bacterial infections transmitted primarily during sexual contact. Less attention has been paid to children, especially girls, who are presumed not to be sexually active and to be protected within their homes from sexual predators. Medical views about how girls become infected changed dramatically in the nineteenth and twentieth centuries. From the 1890s to the 1940s, doctors did not rely on medical research, but modified their medical views to conform to their assumptions about the type of men they believed capable of sexually abusing children.
Venereal disease has a long history, with major epidemics recorded, for example, in the late fifteenth century in Europe. In popular belief, problems were usually associated with adults, not children, and particularly with the growth of cities and, in the United States, with the arrival of new immigrant groups whose sexual habits seemed suspect. Growing awareness of prostitution and urban red light districts fed concern. Again, actual problems focused primarily on adults, but venereal disease warnings to children amplified nineteenth-century sexual advice, providing yet another reason to urge children to avoid premarital sexual activity. Warnings of this sort continued in the twentieth century, and by the 1960s new patterns of adolescent SEXUALITY, and new venereal diseases, redefined the whole problem both in advice and in actual disease incidence.
Historically, venereal disease has referred primarily to syphilis and gonorrhea, for which no effective cure existed until researchers discovered penicillin in the 1940s. Although antibiotics have nearly eliminated syphilis from the United States, many new infections, which physicians now refer to as sexually transmitted diseases (STDs), have been discovered. The Centers for Disease Control and Prevention (CDC) have identified twenty-five STDs and estimate that each year in the United States more than 15 million people become infected with at least one; 65 million people in the United States are infected with an incurable STD, such as human immunodeficiency virus (HIV) or genital herpes. Most of the children who acquire HIV, which can lead to AIDS, acquire it from their mothers. As of December 2000, more than 9,000 children and 45 adolescents in the United States had died of AIDS.
Rates of STD infection in the United States may differ by race, ethnicity, class, age, and geographic location, and because of factors such as inadequate health education or access to medical care. But there is no way to know how many people are infected. Statistics are unreliable because only doctors in public health clinics, where most of the patients are poor and people of color, consistently report new infections. In addition, some people never experience any symptoms and others hide infections because they carry a social stigma.
One quarter of the reported infections are among adolescents, who are particularly vulnerable to chlamydia and gonorrhea. The CDC estimate that 3 million people become infected with chlamydia, and over 1 million with gonorrhea, each year; 40 percent of reported chlamydia infections are among adolescent girls, who also have the highest rates of gonorrhea. The CDC has found not only that untreated infections can lead to infertility but that gonorrhea infection, coupled with unprotected sexual contacts, can also facilitate the transmission of HIV, drastically increasing the risk of infection.
As troubling as these numbers are, very little data exist about the numbers of infected children. Most doctors never test children for STDs except as part of a medical investigation for evidence of CHILD ABUSE; when they do, gonorrhea is the single most common diagnosis. Physicians report more than 50,000 gonorrhea infections in children each year. A sexually transmitted disease can spread without penetration, and because genital bruises may disappear quickly, an STD may be the only physical evidence of sexual assault. Gonorrhea is particularly important evidence because the bacteria cause an infection at the point where they enter the body. Boys and girls both suffer from gonorrhea in the rectum and throat, but the vast majority of children diagnosed with an STD, in 1900 as well as 2000, were prepubescent girls with vaginal gonorrhea. What has changed is the medical explanation for how girls become infected.
Although most doctors in the nineteenth century believed that venereal (by which they meant "immoral") diseases originated with prostitutes and spread during sexual intercourse, doctors knew that children also became infected. Doctors expected to find children infected with syphilis or gonorrhea of the eyes, which mothers transmit to their babies. But genital gonorrhea was neither routine nor acquired at birth; most infected children were poor, working-class, or African-American girls who claimed to have been sexually assaulted. Doctors considered these infections important evidence that a girl had been raped, sometimes by her father.
However, when scientific advances at the end of the nineteenth century improved doctors' ability to detect venereal disease, their belief about the link between child sexual assault and infection suddenly changed. Physicians realized not only that venereal disease had spread among Americans from every race, class, and ethnicity, but that genital gonorrhea was so widespread among girls that doctors feared it was epidemic. Most of these girls were between the ages of five and nine and did not claim they had been assaulted. By the time record-keeping systems were in place in the late 1920s, girls under age thirteen accounted for 10 percent of reported infections among females.
Doctors were vexed as to how so many girls had become infected, particularly those from white middle- and upper- class families, which white professionals considered respectable. Many white professionals believed that only foreign or ignorant men abused their daughters and so assumed that INCEST occurred only in poor, working-class, immigrant, or African-American families. When the evidence increasingly pointed to men from their own class, doctors, public health officials, social reformers, and educators speculated that girls could become infected from nonsexual contacts with toilet seats, towels, or bedding–modes of transmission doctors had already rejected for adults and boys. Doctors based their speculation on the fact that the epithelial lining of girls' genitals is so thin that it provides little protection against bacteria. They knew it was unlikely that soiled objects could spread gonorrhea because the bacteria dry quickly when exposed to air, yet without proof that even one girl had become infected after using the school toilet, from 1900 to the 1940s, health care professionals ignored the possibility of sexual assault and insisted instead that girls faced the greatest risk of exposure in the school lavatory.
After penicillin was introduced in the 1940s as the first effective cure for gonorrhea, medical interest in the source of girls' infections disappeared. It was not until the 1970s that physicians who specialized in treating abused children began to emphasize the link between gonorrhea infection and child sexual abuse. In 1998 the American Academy of Pediatrics instructed physicians to assume that a child infected with an STD has been assaulted. But many practitioners remain unwilling to believe that white middle- and upper-class fathers abuse their daughters. These doctors and others, whose motivation is to avoid becoming involved in legal proceedings, may simply attribute a child's infection to "source unknown" and send her home.
See also: Contagious Diseases; Epidemics; Pediatrics.
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LYNN SACCO