Book Review

The Wages of Sin: Sex and disease, past and present

N Engl J Med 2000; 343:1127October 12, 2000

Article

The Wages of Sin: Sex and disease, past and present
By Peter Lewis Allen. 193 pp., illustrated. Chicago, University of Chicago Press, 2000. $25. ISBN: 0-226-01460-6

Shortly after his partner of five years was infected with the human immunodeficiency virus (HIV) in 1982, the author found himself besieged and bewildered by public attitudes toward persons with the acquired immunodeficiency syndrome (AIDS). As the death toll mounted, neither the “uncanny silence” of the uninvolved nor the vehement castigation of the self-righteous appeared to constitute an effective response to limit the spread of the illness, to understand its mechanisms, or to prolong life for those afflicted.

This book arises in seemingly equal parts from Allen's bafflement over societal views and his scholarly intuition that such sentiments must be deeply rooted in Western culture. In The Wages of Sin: Sex and Disease, Past and Present, Allen traces the sources of religious and medical beliefs about several diseases that were historically linked with sin, either as cause or cure. What emerges is a series of short portraits of two bona fide sexually transmitted diseases (syphilis and AIDS), two infections transmitted by other routes (leprosy and bubonic plague), and two noninfectious entities (lovesickness and masturbation), limned against contemporaneous cultural currents that all too often pitted religious and medical authorities against the sick, the outcast, and the downtrodden.

The first half of the book, in many ways its strongest part, chronicles contemporary Western attitudes toward medieval lovesickness (a fascinating hodgepodge of emotional lability, insomnia, jaundice, rash, and arrhythmias, culminating in lycanthropy or death unless cured by sexual intercourse), leprosy, syphilis, and bubonic plague. Pulpits, political platforms, and public hospitals resounded with condemnations of any illness thought to derive from sexual congress. The anthropomorphic tenets of Hippocrates, espoused by Galen and others, collided with the doctrine that heavenly salvation is achieved at the expense of earthly happiness. Death's tumbrel carried off lepers who were legally expelled from most major cities in Britain; those with syphilis who were barred from the gates of the Hôtel-Dieu in Paris; and plague victims who were too poor to flee the streets of London. Allen's explorations trace the influence of Islamic traditions on the development of European hospitals, the roots of the implacable conflict between prelates and physicians, and the panoply of “cures” and “treatments” largely dictated by doctors' attitudes of either charity or condemnation. For example, mild treatments such as baths or milk were often prescribed for innocent victims of syphilis, such as children who had been congenitally infected, whereas mercury vapors or cauterization of the urethra was the prescription for the roué. All were unavailing. Occasionally, even well-intentioned physicians suffered. The 17th-century Italian physician Giulio Cesare Vanini, who like Galen advocated sexual intercourse as a cure for lovesickness, was strangled by an iron collar and then burned at the stake by order of church authorities.

Overall, the book benefits from Allen's masterful scholarship in comparative literature and his illumination of historical sources, many of them recondite. Allen writes with an erudition that is enlivened by an engaging vocabulary and a pleasing cadence. Nonetheless, his message is sometimes enervated when the power of a quotation is weakened because the source is questionable. The potency of the statement that “a 1991 survey of U.S. doctors revealed that half of them would refuse to treat people with AIDS if they could, and nearly a third thought there was nothing wrong with this response” is dissipated when the source is revealed to be the author's interview with a medical ethicist. How many physicians were surveyed? How comprehensive was the sample? Where were the primary data published? When such logical questions are left unanswered, readers may lose confidence in the reliability of the data. In addition, a bit of editorial oversight from knowledgeable physicians might have prevented some misapprehensions, such as the mislabeling of leprosy as a sexually transmitted disease (bubonic plague, in contrast, is specifically excluded from this category) or the conclusion that a six-year-old girl with premature adrenarche was the victim of brain damage or parental abuse.

The second half of the book covers only two subjects: the bane of masturbation in the 18th and 19th centuries and the AIDS epidemic in the 20th. Although the former can in no way be construed as a sexually transmitted disease, it fits the author's paradigm in that it evoked enormous social opprobrium and was roundly condemned by religious and medical authorities alike. The shift to a discussion of HIV infection, in the final chapter, may seem abrupt to some; a discussion of genital herpes in the 1970s and 1980s might have provided a more cohesive transition. Nevertheless, AIDS is the topic that infuses this book. The author's introduction makes clear his agenda, and balance is not his goal. For Allen, the attitudes of his fellow citizens in the early years of the AIDS epidemic mirror precisely the benighted beliefs of bygone centuries. The prejudice that certain sicknesses equate with sin was shared, according to Allen, by public figures, private citizens, and many physicians. Perhaps the contents of another recent book, entitled AIDS Doctors: Voices from the Epidemic (Ronald Bayer and Gerald M. Oppenheimer. New York, Oxford University Press, 2000), will serve as expiation.

Margaret K. Hostetter, M.D.
Yale University School of Medicine, New Haven, CT 06519