Dermatológica 152: 363-366 (1976)
Syphilis, Homosexuality and Legislation R. S u h o n e n , J. W a llen iu s , K. H a u k k a , O. E lo an d A. L assus Department of Dermato-Venereology, University Central Hospital, Helsinki
Key Words. Syphilis • Homosexuality • Legislation Abstract. The proportion of cases with fresh syphilis in males contracted by homo sexual contacts in Helsinki before and after the change of the criminal law in 1971 was studied. Since 1971, homosexuality is by law no longer a crime in Finland. In 1964, only 2% of males with fresh syphilis admitted a homosexual contact. The same figure was 8% in 1970, and increased to about 50% in 1974 and 1975. It was concluded that a change of legislation concerning homosexuality, probably by several different routes, changed the proportion of cases of detected homosexually transmitted early syphilis. This was thought to be of special importance for case finding and controlling of the spread of syphilis.
Introduction
Received: March 3, 1976; accepted: March 25, 1976.
Downloaded by: King's College London 137.73.144.138 - 3/6/2018 10:50:59 PM
In recent years there has been an increasing awareness of the part played by homosexual individuals in the spread of venereal diseases. The incidence of homosexually transmitted venereal diseases is higher in big cities [J ef feriss , 1956] as there is a tendency of homosexuals to gravitate to such places [British Co-operative Clinical Group, 1973], The observed frequencies of homosexually contracted infections vary in different clinics, probably as a result of different attitudes of the clinic staffs to homosexuality [F l u k e r , 1966]. Varying attitudes probably also determine to which degree the patients admit homosexual contacts and therefore influence contact tracing. Lately, venereologists have had the impression that the number of men admitting a homosexual source of venereal infection has increased [M o r t o n , 1971].
364
S uhonen/W allenius/H aukka/E lo/L assus
In Finland the criminal law earlier sentenced persons with homosexual contacts to prison for at most 2 years. After the law was changed in 1971 so that homosexuality in adults is no longer a crime, the number of men ad mitting homosexual contacts was highly increased. The present study com pares the proportion of detected persons with homosexually contracted early syphilis at the clinics for venereal diseases in Helsinki before and after the change of the law.
Material and Methods Male patients with early syphilis diagnosed at either the Outpatient Department for Venereal Diseases, University Central Hospital, or the Municipal Outpatient Department for Venereal Diseases, Helsinki in 1964, 1970, 1972, 1973, 1974 and 1975, were included. Early syphilis is defined here as primary, secondary, and latent in the first 2 years of infec tion. The diagnosis was based on the clinical signs of syphilis, dark-field examination, serological tests for syphilis, and, in early latent syphilis in addition, on an acceptably wellestablished date of infection. The serological tests used were the venereal disease research laboratory slide test, the fluorescent treponemal antibody-absorption test, the Treponema pallidum immobilization test, and during the last 2 years, the Treponema pallidum haemagglutination test. During the study period both clinics have been supervised by the same doctors (J.W. and A.L.), but there have been changes in staff. In all cases, interviews for contact tracing also aiming to detect possible homosexuality, were performed. Special attention was paid to patients with extragenital primary ulcers and patients with secondary lesions without recognized primary lesions.
The number of patients included in the present study is reported in table I. In 1964, 2% of the patients diagnosed in Helsinki admitted that the infection had been contracted by a homosexual contact. The incidence had increased to 8% in 1970 showing a further increase in 1972 and 1973, and reached the level of about 50% in 1974 and 1975. The incidence of primary syphilis was about 60% of all in 1964, 1970, 1972 and 1973, but decreased in 1974 to 42% and in 1975 to 36%. In 22 homosexual cases, a primary ulcer was detected (table II). One of these patients also had lesions of secondary syphilis and was therefore classified to this stage of the disease. Five of the 22 primary ulcers were in the anal region and one patient had the primary ulcer in the lower lip. The latter patient had been treated earlier for secondary syphilis.
Downloaded by: King's College London 137.73.144.138 - 3/6/2018 10:50:59 PM
Results
Syphilis, Homosexuality and Legislation
365
Table I. Cases of early syphilis in male patients in different phases of the disease in Helsinki area (number of homosexuals in brackets) Year of diagnosis 1964
1970
1972
1973
1974
1975
Lues primaria Lues secundaria Lues reccns latens
63(1) 21 (1) 13 (-)
28(1) 14(2) 7(1)
34 (5) 4(2) 14(4)
18(2) 1 (-) 7(1)
21 (7) 14(9) 15(9)
20(5) 24 (14) 11 (9)
Total Homosexuals, %
97 (2) 2.1
49 (4) 8.2
52(11) 21.2
26 (3) 11.5
50 (25) 50.0
55 (28) 50.9
Table II. The location of primary ulcers in homosexual patients Gians Sulcus Preputium Frenulum Shaft of the penis Anus Lip Gians + frenulum Gians + shaft Preputium + inguinal flexure
2 6 3 1 1 5 1 1 1 1 22
Total
The incidence of detected cases with homosexually transmitted early syphilis was unrealistically low in 1964 in Helsinki (about 450,000 inhabi tants), when compared with other studies from the same time [S c h u p p l i , 1962], However, only one third of the cases were diagnosed and treated later than in the primary stage, which stresses a really quite low rate of homo sexually transmitted cases in the present series. On the other hand, at that time the influence of the law and the negative attitude of the general pop ulation created by it certainly forced a high proportion of homosexuals to seek private treatment and thus avoided reporting, while others did not have the courage to admit the real source of infection at the public clinics. The result was to a great disadvantage for contact tracing.
Downloaded by: King's College London 137.73.144.138 - 3/6/2018 10:50:59 PM
Dicsussion
366
S uhonen/W allenius/H aukka/E lo/L assus
The present situation, which indicated that about every second case of early syphilis of males in Helsinki is homosexually transmitted compares well with other studies [British Co-operative Clinical Group, 1973; W a u g h , 1972]. The rise of the proportion of homosexual early syphilis was slower in the first 2 years following the change of the law, but in 1974 and 1975 it seemed to reach the level reported by other authors. This is probably not achieved only by the lack of the fear for legal consequences by the patients but also as a result of changed attitudes to homosexuality of the community on the whole. The high proportion of homosexually transmitted early syphilis is further stressed by the lowered incidence of primary syphilis in the male cases in 1974 and 1975, namely, only a little more than one third of the cases in 1964. This might also indicate a real increase of homosexually transmitted syphilis. Primary ulcers were rare in the present series obviously because procto scopy was not performed. One third of the present homosexuals worked in the restaurant field, while most of the remaining homosexual patients were academically educated. This gives a clue for contact tracing since in cases of heterosexually contracted early syphilis the common professions were workers and sailors. The present study shows that a change of legislation concerning homo sexuality has probably, by several different routes, changed the proportion of cases of detected homosexually transmitted early syphilis from a very low level to close to the figures reported elsewhere. This is of special importance for case finding and controlling of the spread of syphilis.
References British Co-operative Clinical Group: Homosexuality and venereal disease in the United Kingdom. Br. J. vener. Dis. 49: 329-334 (1973). F l u k e r , J.L .: Recent trends in homosexuality in West London. Br. J. vener. Dis. 42: 48-49 (1966). J efferiss, F .J.G .: Venereal disease and the homosexual. Br. J. vener. Dis. 32: 17-20 (1956). Morton, R.S.: Sexual freedom and venereal disease, p. 72 (Owen, London 1971).
Schuppli, R .: Über die Bekämpfung der Syphilis bei Homosexuellen. Dermatológica 124: 155-159 (1962).
W augh, M.A.: Studies on the recent epidemiology of early syphilis in West London. Br. J. vener. Dis. 48: 534-541 (1972).
Downloaded by: King's College London 137.73.144.138 - 3/6/2018 10:50:59 PM
R aimo S uhonen, MD, Department of Dermato-Venereology, University Central Hospital, Snellmaninkatu 14, SF-00170 Helsinki /7 (Finland)
Syphilis, Homosexuality and Legislation R. S u h o n e n , J. W a llen iu s , K. H a u k k a , O. E lo an d A. L assus Department of Dermato-Venereology, University Central Hospital, Helsinki
Key Words. Syphilis • Homosexuality • Legislation Abstract. The proportion of cases with fresh syphilis in males contracted by homo sexual contacts in Helsinki before and after the change of the criminal law in 1971 was studied. Since 1971, homosexuality is by law no longer a crime in Finland. In 1964, only 2% of males with fresh syphilis admitted a homosexual contact. The same figure was 8% in 1970, and increased to about 50% in 1974 and 1975. It was concluded that a change of legislation concerning homosexuality, probably by several different routes, changed the proportion of cases of detected homosexually transmitted early syphilis. This was thought to be of special importance for case finding and controlling of the spread of syphilis.
Introduction
Received: March 3, 1976; accepted: March 25, 1976.
Downloaded by: King's College London 137.73.144.138 - 3/6/2018 10:50:59 PM
In recent years there has been an increasing awareness of the part played by homosexual individuals in the spread of venereal diseases. The incidence of homosexually transmitted venereal diseases is higher in big cities [J ef feriss , 1956] as there is a tendency of homosexuals to gravitate to such places [British Co-operative Clinical Group, 1973], The observed frequencies of homosexually contracted infections vary in different clinics, probably as a result of different attitudes of the clinic staffs to homosexuality [F l u k e r , 1966]. Varying attitudes probably also determine to which degree the patients admit homosexual contacts and therefore influence contact tracing. Lately, venereologists have had the impression that the number of men admitting a homosexual source of venereal infection has increased [M o r t o n , 1971].
364
S uhonen/W allenius/H aukka/E lo/L assus
In Finland the criminal law earlier sentenced persons with homosexual contacts to prison for at most 2 years. After the law was changed in 1971 so that homosexuality in adults is no longer a crime, the number of men ad mitting homosexual contacts was highly increased. The present study com pares the proportion of detected persons with homosexually contracted early syphilis at the clinics for venereal diseases in Helsinki before and after the change of the law.
Material and Methods Male patients with early syphilis diagnosed at either the Outpatient Department for Venereal Diseases, University Central Hospital, or the Municipal Outpatient Department for Venereal Diseases, Helsinki in 1964, 1970, 1972, 1973, 1974 and 1975, were included. Early syphilis is defined here as primary, secondary, and latent in the first 2 years of infec tion. The diagnosis was based on the clinical signs of syphilis, dark-field examination, serological tests for syphilis, and, in early latent syphilis in addition, on an acceptably wellestablished date of infection. The serological tests used were the venereal disease research laboratory slide test, the fluorescent treponemal antibody-absorption test, the Treponema pallidum immobilization test, and during the last 2 years, the Treponema pallidum haemagglutination test. During the study period both clinics have been supervised by the same doctors (J.W. and A.L.), but there have been changes in staff. In all cases, interviews for contact tracing also aiming to detect possible homosexuality, were performed. Special attention was paid to patients with extragenital primary ulcers and patients with secondary lesions without recognized primary lesions.
The number of patients included in the present study is reported in table I. In 1964, 2% of the patients diagnosed in Helsinki admitted that the infection had been contracted by a homosexual contact. The incidence had increased to 8% in 1970 showing a further increase in 1972 and 1973, and reached the level of about 50% in 1974 and 1975. The incidence of primary syphilis was about 60% of all in 1964, 1970, 1972 and 1973, but decreased in 1974 to 42% and in 1975 to 36%. In 22 homosexual cases, a primary ulcer was detected (table II). One of these patients also had lesions of secondary syphilis and was therefore classified to this stage of the disease. Five of the 22 primary ulcers were in the anal region and one patient had the primary ulcer in the lower lip. The latter patient had been treated earlier for secondary syphilis.
Downloaded by: King's College London 137.73.144.138 - 3/6/2018 10:50:59 PM
Results
Syphilis, Homosexuality and Legislation
365
Table I. Cases of early syphilis in male patients in different phases of the disease in Helsinki area (number of homosexuals in brackets) Year of diagnosis 1964
1970
1972
1973
1974
1975
Lues primaria Lues secundaria Lues reccns latens
63(1) 21 (1) 13 (-)
28(1) 14(2) 7(1)
34 (5) 4(2) 14(4)
18(2) 1 (-) 7(1)
21 (7) 14(9) 15(9)
20(5) 24 (14) 11 (9)
Total Homosexuals, %
97 (2) 2.1
49 (4) 8.2
52(11) 21.2
26 (3) 11.5
50 (25) 50.0
55 (28) 50.9
Table II. The location of primary ulcers in homosexual patients Gians Sulcus Preputium Frenulum Shaft of the penis Anus Lip Gians + frenulum Gians + shaft Preputium + inguinal flexure
2 6 3 1 1 5 1 1 1 1 22
Total
The incidence of detected cases with homosexually transmitted early syphilis was unrealistically low in 1964 in Helsinki (about 450,000 inhabi tants), when compared with other studies from the same time [S c h u p p l i , 1962], However, only one third of the cases were diagnosed and treated later than in the primary stage, which stresses a really quite low rate of homo sexually transmitted cases in the present series. On the other hand, at that time the influence of the law and the negative attitude of the general pop ulation created by it certainly forced a high proportion of homosexuals to seek private treatment and thus avoided reporting, while others did not have the courage to admit the real source of infection at the public clinics. The result was to a great disadvantage for contact tracing.
Downloaded by: King's College London 137.73.144.138 - 3/6/2018 10:50:59 PM
Dicsussion
366
S uhonen/W allenius/H aukka/E lo/L assus
The present situation, which indicated that about every second case of early syphilis of males in Helsinki is homosexually transmitted compares well with other studies [British Co-operative Clinical Group, 1973; W a u g h , 1972]. The rise of the proportion of homosexual early syphilis was slower in the first 2 years following the change of the law, but in 1974 and 1975 it seemed to reach the level reported by other authors. This is probably not achieved only by the lack of the fear for legal consequences by the patients but also as a result of changed attitudes to homosexuality of the community on the whole. The high proportion of homosexually transmitted early syphilis is further stressed by the lowered incidence of primary syphilis in the male cases in 1974 and 1975, namely, only a little more than one third of the cases in 1964. This might also indicate a real increase of homosexually transmitted syphilis. Primary ulcers were rare in the present series obviously because procto scopy was not performed. One third of the present homosexuals worked in the restaurant field, while most of the remaining homosexual patients were academically educated. This gives a clue for contact tracing since in cases of heterosexually contracted early syphilis the common professions were workers and sailors. The present study shows that a change of legislation concerning homo sexuality has probably, by several different routes, changed the proportion of cases of detected homosexually transmitted early syphilis from a very low level to close to the figures reported elsewhere. This is of special importance for case finding and controlling of the spread of syphilis.
References British Co-operative Clinical Group: Homosexuality and venereal disease in the United Kingdom. Br. J. vener. Dis. 49: 329-334 (1973). F l u k e r , J.L .: Recent trends in homosexuality in West London. Br. J. vener. Dis. 42: 48-49 (1966). J efferiss, F .J.G .: Venereal disease and the homosexual. Br. J. vener. Dis. 32: 17-20 (1956). Morton, R.S.: Sexual freedom and venereal disease, p. 72 (Owen, London 1971).
Schuppli, R .: Über die Bekämpfung der Syphilis bei Homosexuellen. Dermatológica 124: 155-159 (1962).
W augh, M.A.: Studies on the recent epidemiology of early syphilis in West London. Br. J. vener. Dis. 48: 534-541 (1972).
Downloaded by: King's College London 137.73.144.138 - 3/6/2018 10:50:59 PM
R aimo S uhonen, MD, Department of Dermato-Venereology, University Central Hospital, Snellmaninkatu 14, SF-00170 Helsinki /7 (Finland)
