Elliott Bowen

In Search of Sexual Health is a book about syphilis–and specifically, about what past generations of Americans did when they contracted this disease. While there’s a great deal of scholarship on the history of sexually-transmitted infections, relatively few historians have looked at the lived experiences of those who suffered from syphilis. What did this disease mean for them? What did they do to try to restore their health? What kinds of outcomes did they experience from treatment?

NOTCHES: In a few sentences, what is your book about? Why will people want to read it?

BOWEN: I discovered that in the late 19th and early 20th centuries, thousands and thousands of men, women, and children with syphilis traveled to Hot Springs, Arkansas–a famous health resort whose waters were believed to possess remarkable curative properties. Hot Springs was also home to a group of physicians who specialized in the treatment of syphilis, to a military hospital that admitted syphilitic soldiers and veterans, and to the first federally-operated venereal disease clinic in US history. Examining each of these settings, this book is about how social attitudes toward syphilis intersected with cultural ideologies surrounding class, race, gender, and sexuality to shape the medical management of syphilis–that is, the way doctors and patients understood, diagnosed, and treated this disease.

NOTCHES: What drew you to this topic, and what questions do you still have?

BOWEN: I was first drawn to syphilis (in a historical sense, at least!) in grad school, when in a seminar on the history of public health I read Allan Brandt’s book No Magic Bullet: A Social History of Venereal Disease in the United States since 1880. Brandt’s book is a brilliant analysis of how cultural anxieties at the end of the 19th century found expression in a burgeoning discourse on syphilis–which medical authorities identified as the cause of a number of trends they found distressing. Whether it be rising divorce rates and the breakdown of traditional gender norms, immigration and the fears of “race suicide” this helped generate, or concerns about the mental and physical fitness of the soldiers and sailors who made up the country’s armed forces, syphilis figured prominently in diagnoses of America’s social problems. This analysis doesn’t really look at syphilis from what medical historians call “the patient’s perspective.” The focus is largely on public health. Indeed, as Brandt has it, the country’s inability to effectively deal with sexually-transmitted infections is a direct result of the long-standing belief that these are the product of sexual immorality (what past generations of Americans called “the wages of sin”), and as such, are not deserving of the kinds of compassionate medical care extended to the victims of other diseases.

As I thought about this, I began to wonder how much truth there was behind this claim. Did Americans who contracted syphilis see themselves as sinners unworthy of medical attention? Did they find the doors of the country’s medical institutions closed to them, so that suffering in silent, guilty resignation was their only option? These questions served as the impetus to my research; as I looked into them, I found that things were more complicated than most historians had realized. While the belief that syphilis was God’s just punishment for immoral sexual behavior certainly influenced the way people with this disease thought about themselves, it did not necessarily do so in a way that turned them away from medicine. As I argue in the book, one of the things it did was push them away from local sources of medical care and toward those in distant locations–like that offered in Hot Springs. And within this central Arkansas city, doctors offered cures that were simultaneously medical and moral. Gradually, what I came to recognize is that taking a patient-oriented approach to the history of this disease leads to some rather surprising insights. While there is much more work to be done on this, the results of my study suggest that the “sin v. science” framework that has long governed historical analyses of American responses to sexually-transmitted infections is rather simplistic.

NOTCHES: This book is about the history of sex and sexuality, but what other themes does it speak to?

BOWEN: One of the other things my book speaks to is race. That this a key theme of the book is perhaps not surprising, as since the publication of James Jones’ Bad Blood: The Tuskegee Syphilis Experiment in 1981, historians have been attuned to the ways that racism has shaped the country’s struggles with sexually-transmitted infections. This was certainly true in Hot Springs, which remained a Jim Crow city throughout the time period my book focuses on. Institutional racism made it difficult for the city’s Black doctors to gain a foothold within the local medical marketplace, as the vast majority of its hotels, bathhouses, and medical facilities catered only to white health-seekers. Even when Black men and women managed to find accommodations within the city, they still had to contend with the hostility of local white doctors–many of whom subscribed to the idea that African Americans were sexually promiscuous by nature and as such were innately predisposed to venereal infection. In addition to this, white physicians believed that their Black patients were incapable of feeling shame or guilt upon contracting syphilis; because of this, the therapeutic regimen they pursued here included none of the “moral treatment” that was the centerpiece of doctors’ interactions with white patients. Whereas therapy for the latter was comprehensive (engaging the physical, emotional, psychological, and spiritual aspects of syphilis), for Black men and women, this consisted simply of bodily remedies. In carving a color line through syphilis, the resort’s white healers aimed to demonstrate the moral superiority of white patients, thus preventing them from falling into association with a racial “other” believed to be irremediably “syphilis-soaked.”

Race is also a prominent theme in the latter part of the book, which focuses on the VD clinic the federal government set up in Hot Springs after World War I. As I show, racism was just as much a part of public health responses to syphilis as it was a part of individual white doctors’ handling of the disease. Even though the clinic freely admitted Black health-seekers, it did little to care for their extra-medical needs. For example, while the clinic’s director (Oliver C. Wenger, who later became involved with the Tuskegee Syphilis Study) and staff sometimes reached into their own pockets to help white patients afford room and board within Hot Springs, I found no instances of this financial generosity being extended to Black patients. Instead, Black people who failed to comport themselves with a sufficient amount of subserviency  were sometimes accused of violating the clinic’s rules, and expelled from Hot Springs before their courses of therapy had ended. And in 1935, when a cash-strapped Public Health Service set up a transient camp on the outskirts of Hot Springs in order to house, feed, and provide recreation for those receiving treatment at the clinic, it did so in an explicitly racist fashion–forbidding Black men and women from applying for residence within this facility. As these examples indicate, the racialization of early 20th century public health policy can be seen not only in the discrimination and hostility Black Americans met with, but also, in the exceptionally generous, holistic medical and socioeconomic aid extended to white Americans. In highlighting the experiences of those in the latter group, this study provides dramatic new evidence of the gaping racial disparities in medical provision and therapeutic outcomes that are characteristic of modern American healthcare.

NOTCHES: How did you research the book? (What sources did you use and were there any especially exciting discoveries or any particular challenges?)

BOWEN: When I began working on this project, I was initially quite skeptical of my ability to answer the questions I’d started out with. “Syphilis was such a huge taboo back then,” I told myself; “you’re never going to find sources that speak to individual experiences of this disease.” But almost immediately after setting foot into Hot Springs, I came across some documents that set my fears to rest. Within the archives of a local historical society, I was handed a series of letters written by a man from Cleveland who twice journeyed to Hot Springs (in 1905 and 1907) to be treated for syphilis. In this correspondence, he discussed his daily trips to a local bathhouse, interactions with other syphilitic patients, and the things that this disease was doing to his body and mind. Then, shortly after this, I came across another first-hand account–this one, from a man who traveled to Hot Springs from Florida. While there, he regularly corresponded with his wife, keeping her updated on the progress of his illness (which he initially did not suspect was syphilis) and providing a sense of what it was like to be a health-seeker in Hot Springs during the first decade of the 20th century.

Armed with sources like these, I began to realize that my dream of writing a patient-centered history of syphilis might actually be possible. Another source that really helped here was clinical case files. Early on in my research, I was able to locate hundreds and hundreds of individual patient records for the many servicemen treated for syphilis at the Hot Springs Army and Navy Hospital. I spent almost a month looking through these cases–boxes upon boxes of which are kept in the National Archives. They form the core of the third chapter of my book, where I argue that patients–and not new medical technologies like the Wassermann test–were a huge part of the reason behind the medical profession’s knowledge of syphilis improved during the first part of the twentieth century.

I was initially hoping to make use of clinical case files in my chapter on the federal government’s VD clinic. But unfortunately, I was never able to locate these. Aside from a few individual stories told in letters and personal reminiscences, much of the narrative set forth in this chapter comes from the clinic’s aggregate statistics and the private papers of its director. What happened to these patient records is a mystery. On several occasions, officials from the Public Health Service make reference to them, so they must have been created and stored somewhere. But either they were destroyed or lost. Had I been able to locate these records, I would have been able to shine a much brighter light on some of the phenomena I investigate in the book.

NOTCHES: Whose stories or what topics were left out of your book and why? What would you include had you been able to?

BOWEN: One thing I wish I could’ve talked more about in the book is the experiences of women with syphilis. Everything I read suggests that the majority of those who traveled to Hot Springs were men, and in the book’s first chapter, I try to explain the various forces and factors that prevented prospective female health-seekers from doing this. But despite the gender imbalance, we do know that women were among those receiving treatment for syphilis in Hot Springs, and throughout the book, I try to shed light on what things were like for them there. This is just a lot harder to do than it is for men–whose writings have been preserved to a much greater extent than women’s. In my research, I was only able to locate one first-hand account from a woman who visited Hot Springs, and since she was neither infected with syphilis nor seeking treatment for any disease, I couldn’t really make use of it. For the most part, what I say about women, syphilis, and Hot Springs comes through other kinds of primary sources: the writings of governmental officials, statistical data, and published articles from medical journals.

Another topic I wish I could’ve done more justice to is homosexuality. The documentary record indicates that local doctors were quite keen on uncovering whatever “sexual perversions” their patients might have engaged in. A few suspected that at least some of the men they were treating had acquired syphilis through “unnatural” means like anal sex, and in fact, in the 1920s, one resident physician proposed that the federal government create a “mental hygiene” clinic in Hot Springs so as to provide psychological treatment (read: conversion therapy) to those suspected of harboring “homosexual tendencies.” Nothing ever came of this effort, but still, the archival evidence suggests that fears of homosexuality might have impacted the treatment protocols adopted by resident healers. When writing the book, I didn’t feel I could substantively speak to this, and so I left it out. In the future, I hope I can get into this a bit more, and in fact, I’m currently doing some research on medical understandings of the relationship between homosexuality and VD during the early 20th century.

NOTCHES: How do you see your book being most effectively used in the classroom? What would you assign it with?

BOWEN: In Search of Sexual Health engages with a number of different historiographies, and because of this, I could see this book being assigned in a variety of different courses.

Most obviously, I hope it will find a natural home in classes on the history of sexuality–especially those devoted to exploring the intersections between gender, sexuality, race, class, and the body. Courses of this sort usually spend at least a week on sexually-transmitted infections, and in this context, my hope is that students will pick up on one of the key arguments of the book: that instead of being infectious disease threats that surfaced only during wartime, syphilis and gonorrhea were part of the daily existence of thousands of Americans who lived prior to the advent of antibiotics. In addition to being a target of state-led preventive public health efforts, for a significant part of the US population, these maladies were a constant, chronic companion–an embodied reality that impacted all aspects of life (including family relations, work, and personal identity) for long periods of time. In this sense, one nice book to pair mine with might be Lynn Sacco’s Unspeakable: Father-Daughter Incest in American History. Detailing the medical profession’s response to a perceived epidemic of vulvovaginitis among American girls during the late nineteenth- and early twentieth-century, Sacco’s work reveals how gendered assumptions, attitudes toward sexuality, and racial beliefs entered into the clinic. Sacco’s book shares with mine an interest in understanding how broader cultural understandings of VD influenced the work of privately-practicing physicians, and in how these understandings complicated the personal and social lives of the sick. Like mine, her book offers concrete evidence of how syphilis is “enmeshed in wider relations of power and inequality.”

I would also recommend my book in classes that explore the historical relationship between health, medicine, and the environment. In the last twenty years, one of the most exciting discoveries to come out of research operating at the intersection of these topics is the phenomenon of “health-seeking” (or, as it would be called today, “medical tourism”). As scholars like Greg Mitman (author of Breathing Space: How Allergies Shape Our Lives and Landscapes) and Conevery Bolton Valenčius (author of “The Health of the Country:” How American Settlers Understood Themselves and Their Land) have demonstrated, the decades following the US Civil War witnessed a veritable “health rush,” and as Americans traveled all across the country “chasing the cure,” and from this was born a new curative industry: the health resort. The existing scholarship on this topic focuses mostly on tuberculosis and the American West, looking at how consumptive “lungers” were largely responsible for the creation of cities such as Denver, Santa Fe, and Los Angeles. Unexplored has been the role that sexually-transmitted infections played in stimulating health travel during this period, and on how this fueled the rise of resorts like that created in Hot Springs, Arkansas. In addition to this, because it centers the experiences of health-seekers and their doctors (not civic boosters or resort promoters), In Search of Sexual Health opens a new window onto the history of medical tourism.

NOTCHES: Now that your book is published, what’s next?

BOWEN: Now that this book is out in the world, I’m planning to undertake a new project exploring the relationship between VD and homosexuality in early 20th century. The impetus for this comes largely from things I discovered while learning about Hot Springs, but my thinking on this topic has also been spurred along quite a bit by the work of Richard McKay–whose “Before HIV” project has drawn attention to a rather interesting aspect of pre-AIDS history: that prior to the mid-20th century, doctors mostly did not associate same-sex encounters with VD. Some even believed that same-sex sexual intercourse actually reduced one’s risk of contracting syphilis or gonorrhea. What explains this? Why were medical understandings of the connection between VD and homosexuality in the early 20th century the exact opposite of what they became in the mid-to-late 20th century? McKay’s research offers some important insights into this question, but on the whole, there hasn’t been a lot of research on this topic. So in my research, I’m hoping to provide a deeper understanding of medical thinking around syphilis and homosexuality during the late 1800s and early 1900s. Right now, I’m in the very early stages of this, so I’m not sure what it will ultimately result in. But whether it’s a one-off article, a new book, or a conference paper, I’m really excited by what I’ve discovered so far, and think this is an incredibly important thing to look into. Without a doubt, this research this will be occupying my mind for the next little while.

Elliott Bowen is an assistant professor of history at Nazarbayev University in Astana, Kazakhstan. His research revolves around the relationship between medicine and sexuality, and he is the author of In Search of Sexual Health: Diagnosing and Treating Syphilis in Hot Springs, Arkansas, 1890-1940 (Johns Hopkins University Press, 2020).

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