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Chapter X: Lysol and Zonite
Facts and Frauds in Woman's Hygiene
by Rachel Lynn Palmer and Sarah K. Greenberg, M.D.
The Sun Dial Press, New York, 1936

Mrs. Robert Smith, married for two months, and living in a small Colorado town, was turning the pages of the Ladies Home Journal. She came to a picture of the Dionne quintuplets. She was a normal young woman and these engaging babies appealed to her. But just the same she found herself hoping that she wouldn’t have a baby until Robert was earning a little more than $28 a week. Their old family doctor had been of no help, and Mrs. Robert Smith had never heard of a birth control clinic, so she clipped the coupon at the bottom of the page and sent for the booklet containing “facts about Feminine Hygiene and other uses of Lysol.”

“Your ritual of personal antisepsis,” the booklet told Mrs. Smith, “Must cleanse thoroughly, destroy germ-life, and leave you soothed and refreshed. Obviously, the effectiveness of your practice of feminine hygiene depends on the preparation you employ in your douche. LYSOL is ideal for this purpose.”

Mrs. Smith bought a bottle of Lysol. She was sure that it must be a good product or it would not be advertised in the Ladies Home Journal and other magazines that she and her mother had read for years.

Just what is this Lysol, used by the Mrs. Robert Smiths of our country “as a means to intimate feminine daintiness and peace of mind”? It consists essentially of cresol, a distillate of wood and coal, which has been made soluble in water by treating it with soap. Cresol was discovered through the attempts of scientists to find a substance which would not be so poisonous as carbolic acid and yet as effective in killing germs. It is now recognized to be almost, if not equally, as dangerous as carbolic acid itself; swallowing Lysol has come to be a common – but extremely painful – means of committing suicide.

Lysol is “SAFE,” says the Lehn and Fink Company, makers of this product. It takes more than the word “safe” in capital letters to refute the many cases, in medical literature, of injury and even death from Lysol. The United States Dispensatory reports the death of a woman from using Lysol in a vaginal douche. As long ago as 1911 Witthaus and Becker stated in Medical Jurisprudence, Forensic Medicine and Toxicology that they had collected the reports of eleven poisonings from uterine irrigations with Lysol. Five of the poisoned women died. In the Journal of the American Medical Association (June 29, 1935), Dr. Louis Pancaro tells of the death of a young woman who injected Lysol into her uterus in order to bring about an abortion. Within half an hour of doing so, the girl became delirioius and unconscious, and died two days afterward without regaining consciousness.

Any antiseptic should be considered not only from the point of view of its effect on bacteria, but also from the point of view of its action on the body tissues. Obviously, any antiseptic which does more damage to the body tissues than it does to the invading bacteria is dangerous. Dr. John R. Conover and Dr. John L. Laird in the Therapeutic Gazette for February, 1924, had this to say of the phenol group of antiseptics: “Members of this group while efficient in destroying bacteria are equally deleterious to animal tissues … Phenol and cresol, as well as the modified preparations, Lysol, kreso, izal, creolin, etc., have an irritating and toxic action …”

The mucous membranes of the vagina are considered so sensitive and easily injured that the Council on Pharmacy and Chemistry of the American Medical Association will not authorize the advertising of any antiseptic to the public for use on the genito-urinary tract. Yet Lehn and Fink, makers of Lysol, urge frequent vaginal douching with their caustic product.

As pointed out in Chapter 8, douches containing strong antiseptics are a common cause of leucorrhea. Dr. Samuel R. Meaker reports in the Journal of Contraception (March, 1936) that he has seen four or five cases of severe inflammation of the vagina “following the employment of a coal-tar-product widely advertised to the laity for feminine hygiene.” He does not name the product, but the description would fit either Lysol or some very similar product. The woman who follows instructions enclosed with each package of Lysol and douches “several times a week” will not find the treatment “soothing.” But she may discover that the douches have brought on an inflammation of an originally healthy vagina.

If the vagina is already inflamed, and the woman troubled with leucorrhea, douching with a caustic substance such as Lysol is apt to aggravate the condition. Dr. James E. King in the New York State Journal of Medicine for February 11, 1933, said that even doctors sometimes err in this direction in their treatment of leucorrhea. “He [the physician] fails to visualize the irritated vaginal walls and the denuded areas, and prescribes a douche that is irritating. Iodine, Lysol, or some douche powder is often his choice.” Dr. King points out that the use of such agents on inflamed surfaces is so irritating that it actually increases the amount of discharge.

“It is used in delicate childbirth when feminine membranes are most sensitive. Then surely it is safe for normal everyday use.” This, or a similar statement, has appeared in many Lysol advertisements in an attempt to reassure women regarding the safety of the product. A truer statement would be that it has been used in childbirth, but that this use is now largely discredited. Dr. Lawrence P. Garrod, Lecturer in Biology at the St. Bartholomew’s Hospital in England says: “To those familiar with the properties of germicides the use of Lysol in obstetrics has always appeared mistaken. It is the most caustic of all antiseptics in clinical use, with the single exception of phenol, and the limitations imposed by this property on the strengths of solutions employable bring them dangerously near a point at which they are ineffective.” Dr. Garrod, in a study which he made of the efficiency of antiseptics used in midwifery, found that a dye known as brilliant green proved to be over fifty times as effective in killing germs as Lysol. Dr. J.M. Munro Kerr reports that when St. Mary’s Hospital in Manchester, England, substituted Lysol for another antiseptic at childbirth, the fever rate became very much higher.

Many doctors have abandoned the use of antiseptics in the vaginal canal during childbirth, for they have found that frequently the damage to the delicate cells of the vagina and cervix is greater than the damage to the bacteria which may be present. Too often the antiseptics cause the very infection they are supposed to prevent.

Every reader of the popular women’s magazines probably remembers the long series of ads which the Lysol makers ran a year or two ago called “frank talks by eminent women physicians,” which were all based on the inference that women could free themselves of the fear of unwanted pregnancies by using Lysol douches. These advertisements were strikingly similar in some respects. For instance, in all that we have seen the doctors quoted were from foreign countries: Dr. Anne Marie Durand-Wever, “distinguished German gynecologist;” Dr. Anna Baltischurler, “leading gynecologist of Switzerland;” Dr. Clotilde Delaunay, “leading gynecologist of Paris;” Dr. Paul Karniol-Shubert, “one of the most distinguished gynecologists of Austria;” Dr. Louise Foucart-Fassin, “leading gynecologist of Brussels;” Dr. Amparo Monmeneu, “famous gynecologist of Madrid, Spain.” One would think that America had no gynecologists of distinction; or perhaps American names are not sufficiently bizarre to embellish a Lysol advertisement.

Another marked similarity is the sameness of the testimonials from these doctors, even in the phrases they use. Thus the Austrian, Dr. Paula Karniol-Shubert, says of one of her patients: “Sound advice on marriage hygiene was all she needed. And that was all I gave her. In two little words: Use ‘Lysol.’” And Dr. Clotilde Delaunay of Paris says that her advice to her scores of patients “is given in two short words – use ‘Lysol.’” That two doctors of different countries should express themselves in such nearly identical language should certainly be investigated by the Society for Psychical Research as a striking illustration of thought transference.

“The Lysol advertising, playing up the testimonials of foreign physicians, is reminiscent,” says the Bureau of Investigation of the American Medical Association, “of what the Fleischmann people were doing in recent years, and some others long before them. It seems likely that ‘patent medicine’ concerns have to resort to testimonials from foreign physicians because reputable ones in America will not sell themselves out to such schemes. It appears, also, that the foreign physicians’ testimonials are not often found in publications issued in their own countries. Possibly they hope that their fellow countrymen will not see their testimonials in American periodicals.”

In these, and many other advertisements, it is implied that Lysol is a safe contraceptive measure. The same inference is made in the leaflet in the Lysol package when it says: “The douche should follow married relations as a cleansing and antiseptic agent.” We have already pointed out in the chapter on douching that no douche, no matter what it contains, is an effective contraceptive, for frequently the spermatozoa have entered the uterus, made their way into the Fallopian tubes and impregnated the ovum before any douche can reach them. Or they may have found their way into some of the innumerable folds of the vagina. No douche can be depended upon to penetrate all of these folds, despite the very brash and positive assertion that “Lysol has that rare quality of penetrating into ever crevice and furrow of the membranes, destroying germ-life even in the presence of organic matter.”

Even putting aside the fact that the douche is an unreliable contraceptive, Lysol is less effective than many other chemicals. In a study of the spermicidal powers of a group of chemicals, Dr. John R. Baker has found that seventeen are more efficient than cresol in killing spermatozoa. (As said before, Lysol and cresol are essentially the same.) Such a harmless substance as the citric acid of lemons ranks ahead of cresol. Yet the manufacturers of Lysol advertise:

Women are sensitive – shy. Down deep in their hearts they know what’s the matter. But something keeps them from telling – even their doctor – and from listening to her advice when she has guessed the truth. Such a case came to my notice recently. I could see my patient thought it ‘wasn’t nice’ to face the problem of marriage hygiene frankly. So I sent for her husband. ‘I’m sorry I had to send for you,’ I told him. ‘But your wife won’t listen. Now you must teach her what to do.’ I explained about ‘Lysol’ – the antiseptic that can always be trusted. I told him how safe it is – how gentle. I told him that the whole medical world approves, uses, recommends it. He went away comforted. And when I next saw his wife, her fears had vanished like dew in the sun. They had both grown young again.

Such sentimental trash would be laughable were it not for the tragedy of the many women who have become pregnant because they have relied upon antiseptic douches.

Two doors from the home of the hypothetical Mrs. Robert Smith who bought Lysol lived Mrs. David Jones – also a typical American wife. Her attention was caught by the picture of a beautiful and radiant woman proclaiming, “Now I’m so much happier.” Mrs. Jones, who had four children, was also struck by the caption, “It’s never too late for a wife to learn.” She read the advertisement and found that Zonite is both “safe and powerful.” And so she bought a bottle.

What is Zonite which the Mrs. Joneses of the country have been told provides the “ideal combination of strength and safety” needed for the purpose of feminine hygiene? It is essentially sodium hypochlorite in water, a very cheap solution. For many years hypochlorite solutions have been known to be of value in the treatment of infections, but they were also known to have decided drawbacks – they were unstable and deteriorated rapidly, and they contained free alkali, which is irritating to body tissue. During the war two surgeons evolved a hypochlorite solution which has been named after them – the Dakin-Carrel solution, and it was used with success on wounds. Zonite is essentially a double-strength Dakin-Carrel solution.

The Zonite Corporation claims that Zonite “keeps its strength indefinitely.” William H. Zabel has reported the experience of St. Luke’s Hospital in Chicago with hypochlorite solutions. St. Luke’s Hospital has tried various processes for making Dakin’s solution, and has also investigated the “concentrated stabilized solutions that are available to be diluted for use.” The judgment formed as the result of this investigation was that “Dakin’s solution, regardless of the method of preparation, loses its efficiency after forty-eight hours, and on longer standing, secondary products form which irritate the wound. Adding chemicals to stabilize the solution interferes with the reaction on micro-organisms.” It is difficult to see in the face of such evidence (confirmed by reports from other scientists) how the claim that Zonite keeps its strength indefinitely can be substantiated. And the chance that a woman can get a fresh bottle of Zonite is extremely small. Quite possibly the bottle has stood on the druggist’s shelf for several weeks, or even longer. At the best it is as old as the time it has taken it to pass through the hands of the manufacturer, the wholesaler, and the druggist.

Zabel reports that Dakin’s solution can be made with an electrolytic cell for about four cents a gallon. Zonite, also manufactured by an electrolytic process, sells for 30 cents for a two and one-half ounce bottle and 60 cents for the six-ounce size. According to Zabel’s cost estimate, and allowing for Zonite’s double strength, the bottle retailing at 60 cents contains about one-half cent’s worth of the solution.

All doctors know that if Dakin’s solution is to be used successfully it must not contain caustic alkali, and its strength must be maintained within a very narrow range. If it is too weak, it is ineffective; if too strong, it seriously irritates the tissues. Many doctors do not use Dakin’s solution because it is difficult to get just the right strength. It seems almost unnecessary to say that the woman who measures her Zonite with a tablespoon and who makes a rough estimate of the water by merely filling up her douche bag is not able to improve on the doctor’s technique.

What about the claims of Zonite that it is non-irritating? In treating wounds with Dakin’s solution it is necessary to cover the surrounding normal tissue with gauze soaked in Vaseline in order to protect it. Any antiseptic that may injure the skin may certainly irritate the mucous membranes of the vagina. Dr. Robert A. Lambert has reported in the Journal of Experimental Medicine that Dakin’s solution is among the antiseptics which are more injurious to tissue cells than to bacteria. Any woman who douches often with Zonite is running a risk because douching frequently with any antiseptic may be harmful. By killing or injuring the protective Doderlein bacilli, and by possibly irritating the mucous membranes, she is inviting an attack of vaginitis. When the Zonite Products Corporation states that “the douche has become a fixed part of the feminine toilet, recognized as a wholesome, healthful routine;” when they claim that Zonite when used as indicated in the vaginal douche is “non-irritating” and “exercises no harmful effect on the delicate membranes and tissues of the vaginal tract,” they are guilty either of ignorance or a callous indifference to the health of the countless women whom they are trying to enlist as steady buyers.

“Nearly every woman at one time or another is afflicted by leucorrhea (‘whites’), characterized by a whitish, viscous discharge. A Zonite douche will help to relieve the inflammation and to disinfect and cleanse the affected parts. When convenient, a tampon of absorbent cotton may be used. This should be moistened well with the solution…” says “Facts for Women,” the booklet put out by the Zonite Corporation. We have already pointed out the dangers of self-treatment of leucorrhea. Use of the tampon, which would keep Zonite in prolonged contact with the mucous membranes, is particularly unwise. “Caution,” read the Zonite leaflets. “Do not let Zonite come in contact with dyed fabrics; the active principle is a powerful bleaching agent.” Yet no caution is given regarding the possible injury resulting from the introduction into the vagina of a tampon saturated with a solution of the same powerful bleaching agent.

The Zonite people at the present time are basing their appeal to women on the inference that Zonite is a good contraceptive. “Many a home is peaceful and happy … when fear and doubt no longer cloud the young wife’s outlook.” The continuous barrage of such statements justifies a final reminder that the douche is not a reliable contraceptive measure. One advertisement reads: “There are sensitive women everywhere who do not trust the superficial information that is going around about feminine hygiene. These deep-natured women want the whole truth from the scientific standpoint. They must depend on themselves to sift out the read facts.” It is to be hoped that enough has been said to make women, deep-natured or otherwise, realize that for the facts they must go elsewhere than to the Zonite Products Corporation.

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Part 1 of 2

Vaginal Douching: Evidence for Risks or Benefits to Women's Health
by Jenny L. Martino and Sten H. Vermund
Epidemiol Rev. 2002; 24(2): 109–124.

INTRODUCTION

Vaginal douching is the process of intravaginal cleansing with a liquid solution. Douching is used for personal hygiene or aesthetic reasons, for preventing or treating an infection(1), to cleanse after menstruation or sex, and to prevent pregnancy (2). For at least 100 years, there have been conflicting views on the benefits or harm in douching. Although there is a broad consensus that douching should be avoided during pregnancy, there is less agreement regarding douching for hygiene and relief of vaginitis symptoms. Two earlier reviews of douching data in women (3) and adolescents (4) have concluded that douching is harmful and should be discouraged because of its association with pelvic inflammatory disease, ectopic pregnancy, and perhaps other conditions. Nonetheless, douching continues to be a common practice. We seek to review the evidence of the impact of douching on women's health.

METHODS

Studies included in this review were identified via a search of the computerized MEDLINE database from 1965 through March 2002. Only English-language articles were included, as were a few relevant articles published before 1965. Major medical and nursing organizations were contacted for their policy and educational documents. Via a Freedom of Information request, we secured a summary of the Nonprescription Drug Advisory Committee meeting held on April 15, 1997, from the US Food and Drug Administration.

EPIDEMIOLOGY OF DOUCHING

Douching products (table 1), methods, frequency, motivation, and timing can vary considerably among women who douche. The prevalence of douching has decreased since 1988, but it is still a common practice among American women, especially adolescents, African-American women, and Hispanic women (table 2) (1, 5). In 1995, 55 percent of non-Hispanic Black women, 33 percent of Hispanic women, and 21 percent of non-Hispanic White women reported “regular” douching (5). In the United States, there have been reports of 52-69 percent of adolescents douching at least once and one study documenting 56 percent reporting douching one or more times a week (2, 6-8). In addition, douching is prevalent in some African countries, such as Côte d'Ivoire, where the douching rate among women has been reported to exceed 97 percent (9). It is uncommon for women to douche daily; sporadic douching is more common (1, 8). A dose-response relation between douching and its adverse effects has been found by some, highlighting the importance of assessing douching frequency in any related research (10-14). The intensity and method of douching, especially douching with pressure, have been associated with adverse outcomes (15).

TABLE 1

Some vaginal douching products*

Ingredients / Function / Commercial / Home preparation

5% acetic acid (vinegar) / Acidifying agent / X / X
Benzoic acid, citric acid, lactic acid, sorbic acid / Acidifying agents / X / --
Bleach (sodium hypochlorite and sodium hydroxide) / Cleanser / X/ --
Cetylpyridinium chloride / Antimicrobial, antiseptic, germicidal, surfactant / X / --
Decyl glucoside / Nonionic detergent, mild surfactant, solubilizes water-insoluble materials / X / --
Diazolidinyl urea / Acidifying agent / X / --
Disodium EDTA,† edetate† disodium / Preservative, antibacterial agent, metal chelator (binds magnesium and calcium) / X / --
Lysol (alkyl 50% C14, 40% C12, 10% C16, dimethylbenzyl-ammonium chloride 2.7%; Reckitt & Coleman, Wayne, NJ) / Cleanser / -- / X
Octoxynol-9 / Surfactant, produces a mucolytic or proteolytic effect, spermicide / X / --
Povidone-iodine‡ / Antimicrobial / X / --
SD Alcohol 40† / Liquid vehicle / X / --
Sodium benzoate / Preservative (prevents bacteria from growing in solution that contains citrate and lactate) / X / --
Sodium bicarbonate (baking soda) / Alkalizing agent / X / X
Sodium citrate / Acidifying agent / X / --
Sodium lactate / Acidifying agent / X / --
Water / Liquid vehicle, cleansing / X / X
Yogurt / Potential source of nonhuman strain of lactobacillus / -- / X

*Sources: Handbook of Nonprescription Drugs. Washington, DC: American Pharmaceutical Association and the National Professional Society of Pharmacists, 1982; and Dr. Dennis Pillion, Pharmacology Department, University of Alabama at Birmingham, personal communication, 2001.
†EDTA, ethylenediaminetetraacetic acid; edetate, ethylenediaminetetraacetate; SD Alcohol 40, specially denatured alcohol, followed by a number or a number-letter combination that indicates how the alcohol was denatured, according to the formulary of the US Bureau of Alcohol, Tobacco, and Firearms.
‡Medicated douches.

TABLE 2
Percentage of women who douche regularly, by age and race/ethnicity, according to the National Survey of Family Growth, United States

Year and reference / Sample size(no.) / Age (years) / Total (%) / Non-Hispanic Black (%) / Non-Hispanic White (%) / Hispanic (%)

NSFG,*1995(5) / 10,847 / 15-44 / 26.9 / 55.3 / 20.8 / 33.4
NSFG,*1995(5) / 10,847 / 15-19 / 15.5 / 36.8 / 10.8 / 16.4
NSFG,*1995(5) / 10,847 / 20-24 / 27.8 / 60.4 / 20.4 / 32.5
NSFG,*1995(5) / 10,847 / 25-29 / 30.0 / 58.7 / 23.9 / 38.0
NSFG,*1995(5) / 10,847 / 30-34 / 30.6 / 60.4 / 24.5 / 35.1
NSFG,*1995(5) / 10,847 / 35-39 / 28.9 / 62.5 / 21.9 / 41.2
NSFG,*1995(5) / 10,847 / 40-44 / 26.9 / 53.1 / 21.1 / 38.5

Year and reference / Sample size(no.) / Age (years) / All races (%) / Black (%) / White (%)

NSFG, 1988(1) / 8,450 / 15-44 / 36.7 / 66.5 / 32.0
NSFG, 1988(1) / 8,450 / 15-19 / 31.0 / 53.5 / 25.4
NSFG, 1988(1) / 8,450 / 20-24 / 41.1 / 63.1 / 35.7
NSFG, 1988(1) / 8,450 / 25-29 / 37.6 /67.6 / 32.9
NSFG, 1988(1) / 8,450 / 30-34 / 36.0 / 64.8 / 31.5
NSFG, 1988(1) / 8,450 / 35-39 / 35.1 / 70.2 / 30.2
NSFG, 1988(1) / 8,450 / 40-44 / 37.0 / 65.8 / 33.8

*NSFG, National Survey of Family Growth.

The timing of douching may impact on adverse sequelae, such as the temporal use of douching in relation to sexual activity, pregnancy, symptoms, and the menstrual cycle (4, 11, 16, 17). During ovulation, the levels of circulating estrogens increase, the cervical os opens, and the cervical mucus becomes clearer and more profuse (3, 18). Therefore, the risk of ascending infection from the pressure of douching may be greatest around the time of ovulation when the cervical os is gaping and the mucus is thin (3).

Women who douche consider it to be a healthy practice and often state that hygiene is their primary reason for douching (2, 6, 8, 15, 19). Some women state that douching is “necessary for good hygiene” (19). Motives for douching are many: to cleanse the vagina after menses or before or after sexual intercourse, to prevent or ameliorate an odor, to prevent or treat vaginal symptoms such as itching and discharge, and, less commonly, to prevent pregnancy or sexually transmitted diseases (2). Most women report douching for hygienic reasons, while douching due to symptoms may be comparatively uncommon (20, 21). Outside influences such as physicians, mothers, girlfriends, boyfriends, and the media affect a woman's decision to douche (19). The motivation for douching is a complicated issue imbued with both psychologic and social features that need to be addressed if vaginal douching behavior is likely to be modified on any large scale.

HEALTH EFFECTS OF DOUCHING

Douching has been associated with many adverse outcomes including pelvic inflammatory disease, bacterial vaginosis, cervical cancer, low birth weight, preterm birth, human immunodeficiency virus transmission, sexually transmitted diseases, ectopic pregnancy, recurrent vulvovaginal candidiasis, and infertility. Studies conflict, however, and the strength of association varies enormously between studies. Many potentially confounding factors blur the epidemiologic assessment of the consequences of douching. Douching in the United States is more common among African-American women (1, 3, 5, 19). Independently of race, associations between douching and poverty, less than a high school education, a history of pelvic inflammatory disease, and having between two and nine lifetime sexual partners are reported (1). A lower educational level, many sexual partners, and poverty are also risk factors for sexually transmitted diseases and bacterial vaginosis, making it especially complicated to assess causality since women might douche secondary to infection-related symptoms rather than for routine purposes.

Conflicting results are reported regarding sexually transmitted infections and douching. Some studies suggest that adolescents who douche are more likely to have a history of a sexually transmitted disease (1, 15), while other studies have found that women who have a history of a sexually transmitted disease were less likely to douche (1, 10, 22). Prospective studies are needed to assess whether douching is causally related to sexually transmitted diseases or if douching is most commonly a response to symptomatic vaginitis. Whether complications like pelvic inflammatory disease might have occurred even without douching can be answered with prospective studies (1, 23, 24).

PHYSIOLOGY

There are several ways by which douching may contribute to disease. Douching may remove normal vaginal flora, permitting the overgrowth of pathogens. It may also provide a pressurized fluid vehicle for pathogen transport, helping lower genital tract infections ascend above the cervix into the uterus, fallopian tubes, or abdominal cavity (3, 16). These microbiologic and physical mechanisms may work in concert. Ness et al. (25) found that, among a group of women with clinical pelvic inflammatory disease, frequent and recent douching was associated with endometritis and upper genital tract infection in women with normal or intermediate vaginal flora, although this was not noted in women with bacterial vaginosis.

An added concern is that, if douching reduces the density of normal vaginal flora, bacterial vaginosis might develop or there may be a predisposition to colonization by such sexually transmitted pathogens as Neisseria gonorrhoeae or Chlamydia trachomatis, filling the “ecologic niche” (16). Pathogenic bacteria may then ascend into the upper reproductive tract, leading to inflammatory scarring (endometritis, salpingitis, or peritonitis), the principal cause of ectopic pregnancy, early miscarriage, and infertility (16).

Physiologic risk for sexually transmitted diseases is greater among adolescent women, since they typically have ectopic columnar epithelial cells in the exocervix with a large transformation zone that is vulnerable to bacterial and viral sexually transmitted infections (26). Some argue that it is especially important to caution adolescents about the potential adverse effects of douching, as they may be even more susceptible to its adverse consequences (4).

DOUCHING AND VAGINAL ECOLOGY

A healthy menarcheal vaginal environment is composed primarily of lactobacilli (27). Hydrogen peroxide (H2O2)-producing lactobacilli may protect the vagina against the overgrowth of potentially pathogenic indigenous flora and exogenous pathogens. Selected human strains of lactobacilli produce lactic acid that helps keep the vaginal pH low, usually less than 4.5, which is inhospitable to many pathogenic organisms (28). In addition to H2O2 production, lactobacilli adhere to epithelial cells, block pathogen adhesion, and stimulate the mucosal immune system (28).

Newton et al. (29) found that douching more than once per month was associated with the presence of Trichomonas vaginalis (odds ratio (OR) = 3.5, p = 0.02) and that douching one or more times a month was associated with Gardnerella vaginalis (OR = 2.4, p = 0.05). They examined Mexican-American and African-American women and concluded that race (specifically, being African American) had a more consistent association with the presence or absence of a cervical-vaginal organism than other factors, including behavioral variables.

Different types of douching liquids have various antimicrobial effects. Pavlova and Tao (30) used in vitro studies to show that four antiseptic douches were inhibitory against all vaginal microorganisms, including lactobacilli. Three vinegar-containing douches selectively inhibited vaginal pathogens associated with bacterial vaginosis, group B streptococcal vaginitis, and candidiasis, but not lactobacilli, suggesting to the investigators that vinegar (5 percent acetic acid) douches may be less harmful or may be beneficial. Juliano et al. (31) tested seven commercial vaginal antiseptic douche solutions against vaginal lactobacilli and found marked in vitro antibacterial activity, often after very short exposure times. Thus, some douche preparations may cause substantial changes in vaginal flora.

Onderdonk et al. (32) found that healthy women who douched with a 4 percent acetic acid solution experienced a transient reduction of total bacteria that they attributed to the physical washing of the vaginal vault alone. However, when they used povidone-iodine, a bactericidal agent, it caused a significant reduction in total bacterial counts that suggested an antiseptic effect in addition to the washing effect. They concluded that, in some individuals, douching may decrease the vaginal bacteria that are present, allowing a rapid proliferation of potential pathogens, increasing the risk of associated infections. In contrast, Monif et al. (33) found that, while in vivo douching with povidone-iodine caused a dramatic decrease in the total number of vaginal bacteria, baseline counts were reestablished within 120 minutes. They also found that lactobacilli were the first bacteria to recover. As a consequence, Monif (34) has argued for the potential benefits of douching. However, these experiments do not reflect that some women may participate in a behavior that alters the vaginal ecology before it has a chance to return to normal, such as repeated douching or vaginal or receptive vaginal, oral, or anal sex]. The weight of the epidemiologic evidence suggests that repeated douching with its attendant washing and antibacterial effects will diminish lactobacilli predominance and risk reproductive tract infections.

BACTERIAL VAGINOSIS

Bacterial vaginosis is a common cause of malodorous vaginal discharge in women (35). Three million symptomatic cases are reported annually in the United States, but millions more remain unreported or unrecognized (28, 36). A clinical diagnosis of bacterial vaginosis requires three of the following “Amsel criteria”: vaginal pH of greater than 4.5, a positive “whiff” test for amines, presence of clue cells, and a thin homogenous discharge (37). In women with bacterial vaginosis, lactobacilli, especially H2O2-producing lactobacilli, are greatly decreased and the vagina becomes overgrown with anaerobic and facultatively anaerobic bacteria that are often present in small numbers in the normal vagina. These include G. vaginalis, Mycoplasma hominis, Prevotella spp., Peptostreptococcus spp., Mobiluncus spp., and Bacteroides spp. (28, 38-40). Bacterial vaginosis has been reported to be twice as common among African-American and Afro-Caribbean women than among White women (35, 41-44). Vaginal douching is also twice as common among African-American women. It has been proposed that bacterial vaginosis is sometimes sexually transmitted; however, no male factor has been identified, and bacterial vaginosis can occur in adolescent women who have never had sexual intercourse (45).

Bacterial vaginosis is common, and many factors reminiscent of sexually transmitted disease risk are associated with bacterial vaginosis. Schwebke et al. (46) found that 78 percent of women without evidence of genital tract infection had significant, although transient, changes in their vaginal flora. Day-to-day variability was defined as less than 85 percent of a given woman's normal vaginal flora, which was calculated on data from self-obtained vaginal smears from each woman. In a multivariable analysis, more frequent episodes of receptive oral sex were associated with unstable flora. Day-to-day variability in vaginal flora was associated with the use of vaginal medication, menses, greater number of sexual partners, spermicide use, more frequent vaginal intercourse, and less frequent use of condoms. Many of these factors are also associated epidemiologically with bacterial vaginosis and sexually transmitted diseases. It has also been reported that intrauterine device users are more likely to be diagnosed with bacterial vaginosis than are nonusers (47).

Bacterial vaginosis has been linked with several adverse reproductive outcomes, including endometritis (48-51), spontaneous preterm delivery (52-61), preterm delivery of low birth weight infants (62), low birth weight (13), premature rupture of the membranes (52, 55), histologic chorioamnionitis (63), and infection of amniotic fluid (64-66). In a randomized clinical trial, Hauth et al. (67) studied pregnant women with bacterial vaginosis who also had a high risk for preterm delivery. Antepartum metronidazole and erythromycin lowered the frequency of prematurity. However, two other studies found that vaginal clindamycin for treatment of bacterial vaginosis did not decrease the rate of preterm deliveries (68, 69). The frequency of vaginal douching was shown by Fiscella et al. (13) to have a dose-response relation with the likelihood of low birth weight. If a pregnant woman has bacterial vaginosis and douches, chronic bacterial colonization of the endometrium and/or chorioamnion may cause preterm rupture of the membranes and/or preterm labor (70). Meis et al. (60) found that the presence of bacterial vaginosis at 28 weeks' gestation is associated with an increased risk of spontaneous preterm birth, defined as birth at less than 35 weeks. This association is strongest for early preterm birth and may be mediated by subclinical chorioamnionitis (71).

Douching is associated with bacterial vaginosis, although the direction of causation is uncertain: Does douching predispose to bacterial vaginosis, or do women douche in response to bacterial vaginosis symptoms? In a cross-sectional study, Holzman et al. (72) found that vaginal douching within the past 2 months was associated with an increased prevalence of bacterial vaginosis (OR = 2.9, 95 percent confidence interval (CI): 1.5, 5.6). Fonck et al. (73) found that, in female sex workers in Nairobi, Kenya, douching in general and douching with soap and water were both significantly associated with bacterial vaginosis, with a significant trend for increased frequency of douching and higher prevalence of bacterial vaginosis. In an important recent prospective cohort study, Royce et al. (74) found that douching was associated with bacterial vaginosis (risk ratio (RR) = 1.8, 95 percent CI: 1.7, 2.0) and preterm birth (RR =1.6, 95 percent CI: 1.1, 2.1). Rajamanoharan et al. (35) found that bacterial vaginosis was strongly associated with the use of commercial antiseptic products applied to the vulval mucosa or as a vaginal douche. After controlling for genital hygiene behaviors (such as douching and vulval antiseptics) and history of previous bacterial vaginosis episodes, they found that there were no ethnic differences between women with bacterial vaginosis and women without bacterial vaginosis. Hawes et al. (44) found that lack of vaginal H2O2-producing lactobacilli was independently associated with bacterial vaginosis but not with vulvovaginal candidiasis. They also reported that acquisition of bacterial vaginosis was associated with having a new sexual partner and douching for hygiene. Stevens-Simon et al. (75) found that Black adolescents had a more alkaline vaginal pH than did White adolescents, possibly decreasing their resistance to common vaginal infections, such as trichomoniasis and bacterial vaginosis.

Given the frequency of bacterial vaginosis among American women and its associations with adverse reproductive outcomes, the largest attributable risk for which douching may be responsible may be increased bacterial vaginosis frequency. However, the temporal relation has not been well established given the paucity of large, prospective studies.

GONORRHEA, CHLAMYDIA, AND OTHER SEXUALLY TRANSMITTED DISEASES

Many sexually transmitted diseases are asymptomatic and therefore go undiagnosed, particularly in women. Two bacterial sexually transmitted diseases, gonorrhea and chlamydia, are especially important causes of pelvic inflammatory disease. Chlamydia has been associated with tubal infertility due to fallopian tube scarring and obstruction (76-80), ectopic pregnancy (81), and pelvic inflammatory disease (82). In addition, both chlamydia and gonorrhea have been reported to facilitate human immunodeficiency virus transmission (26). Several studies have found an association between douching and chlamydial infection (9, 14, 25, 83-85). However, cross-sectional studies cannot determine reliably whether the douching preceded the disease or if the symptoms led to the douching.

Scholes et al. (14) found that women who reported douching 12 months prior to their clinic visit were twice as likely to have cervical chlamydial infection and that, as the frequency of douching increased, the likelihood of chlamydial infection also increased. Peters et al. (83) found that douching at least monthly was significantly associated with chlamydia in adolescents. Beck-Sague et al. (84) found that, in adolescents who douched monthly or more frequently, there was a higher prevalence of chlamydia. Stergachis et al. (85) found that douching within the last year was independently predictive of chlamydial infection.

Other studies have examined sexually transmitted diseases in general. Foch et al. (7) found that, in adolescents attending a family planning clinic, those who reported douching were more likely to have a history of a sexually transmitted disease. Joesoef et al. (17) found that, among Indonesian pregnant women, douching with water and soap, betel leaf, or a commercial agent after sex was associated with having a sexually transmitted disease and that the association was strengthened among women who douched before sex or both before and after sex. Compared with women who never douched, those who always douched with betel leaf or a commercial agent had a substantially increased risk for sexually transmitted diseases (OR = 9.4, 95 percent CI: 1.8, 50.3). Douching with irritating substances may make the vaginal mucosa more susceptible to sexually transmitted diseases, analogous to the use of intravaginal herbs as drying agents (86). Critchlow et al. found that cervical ectopy, which has been associated with acquisition of certain sexually transmitted diseases, including chlamydia (87, 88) and human immunodeficiency virus (89), was less common among women with sexually transmitted diseases who douched recently (90). Douching and sexual activity both may accelerate squamous metaplasia and cervical maturation (91, 92). Cervical ectopy is common in adolescents and has been associated with increased risk of sexually transmitted disease acquisition, suggesting the importance of measuring all these factors together in studies of douching and health risk (87, 88, 91). Jacobson et al. (91) found that both douching and sexual activity may decrease ectopy in adolescents. If women who douche have less ectopy, they might eventually have a theoretically lower chance to acquire sexually transmitted diseases, although there are no data that suggest this. In contrast to the above studies, Fonck et al. (73) found that, in female sex workers in Nairobi, Kenya, there was no direct relation between douching and the risk for human immunodeficiency virus infection or other sexually transmitted infections. Similarly, Moscicki et al. (92) found no ectopy association with human immunodeficiency virus among US adolescents.

Given the severity of the reproductive consequences of gonorrhea and chlamydia, the associations with douching are worrisome, particularly for chlamydia. As with bacterial vaginosis, the temporal relation is clouded by the paucity of prospective data, hindering clarification of whether douching is a cause or a consequence.

PELVIC INFLAMMATORY DISEASE

Pelvic inflammatory disease is a polymicrobial infection primarily initiated by ascending infection to the upper reproductive tract by N. gonorrhoeae, C. trachomatis, or anaerobic and/or facultative bacteria also occurring with bacterial vaginosis (93-96). It is virtually certain that the physical pressure of douching can facilitate ascension of pathogens (23). Infection, inflammation, and scarring of the fallopian tubes, ovaries, and/or the uterine lining can result in tubal infertility, tuboovarian abscess, endometritis, chronic pelvic pain, recurrent pelvic inflammatory disease, and ectopic pregnancy. Pelvic inflammatory disease affects over 1 million American women and adolescents annually at an estimated cost of $4.2 billion in 1990 (94, 97). The total cost of pelvic inflammatory disease, including both direct and indirect costs, was projected to be more than $9 billion in 2000 (97). It was estimated that 20-30 percent of women with pelvic inflammatory disease would be hospitalized (24) and that at least 25 percent would suffer one or more serious long-term sequelae (97). Guidelines for diagnosis from the Centers for Disease Control and Prevention include complaint of abdominal pain and clinical findings of lower abdominal, cervical motion, and adnexal tenderness (98). Silent pelvic inflammatory disease that goes unreported may account for 50 percent or more of all the cases of pelvic inflammatory disease (99).

About 70 percent of the women diagnosed with pelvic inflammatory disease in the United States are under 25 years of age (100). Risk factors for pelvic inflammatory disease have been found to include being of lower socioeconomic status, non-White, less than 25 years of age, being exposed to a sexually transmitted disease or having a history of pelvic inflammatory disease, use of an intrauterine device, failure to use contraception, multiple sexual partners, and earlier sexual initiation (100, 101). Some of these same characteristics are prevalent among women who douche, and vaginal douching has been associated with pelvic inflammatory disease in most studies (3, 12, 22, 26, 102-107).

Vaginal douching may potentially increase the risk of pelvic inflammatory disease by promoting the ascension of lower genital tract infections to the upper genital tract, by changing the vaginal environment to increase susceptibility to reproductive tract infections that precede pelvic inflammatory disease, or by introducing nonpathogenic vaginal bacteria into the typically sterile upper genital tract (24). The weight of the evidence suggests a causal association of douching and pelvic inflammatory disease, but the lack of prospective studies continues to plague efforts to clarify the causal relation.

As early as 1952, an association between douching and pelvic inflammatory disease was suspected (108). Jossens et al. (106) found that douching after menses was a significant risk factor for pelvic inflammatory disease. Others report uncertainty (109) in the relation between douching and pelvic inflammatory disease or have found vaginal douching to be associated with pelvic inflammatory disease (107, 110) (figure 1) (3, 10, 95, 104, 106, 110, 111). Mueller et al. (111) found that women who douched had moderately elevated risks for overt and silent pelvic inflammatory disease-associated infertility. Scholes et al. (104) found that women who douched during the previous 3 months had an elevated odds ratio for pelvic inflammatory disease of 2.1 after controlling for other risk factors. They also found that there was a dose-response relation as women who douched more frequently had a higher pelvic inflammatory disease risk. In a case-control study, Wolner-Hanssen et al. (10) found that current douching was more common among women with pelvic inflammatory disease and that pelvic inflammatory disease was significantly related to frequency of douching. Neumann and DeCherney (102) found an association between pelvic inflammatory disease and vigorous and frequent (more than once a week) douching. Miller et al. (26) reported douching to have a significant impact on the risk of pelvic inflammatory disease. Forrest et al. (22) reviewed the literature through 1989 and concluded that the weight of published evidence supported an association between vaginal douching and both pelvic inflammatory disease and ectopic pregnancy. Zhang et al. (3) reported in a 1997 meta-analysis that douching increased the risk of pelvic inflammatory disease by 73 percent. Miller et al. (26) found that, from the 1995 National Survey of Family Growth, douching was significantly associated with having pelvic inflammatory disease. Aral et al. (103) analyzed data from the 1988 National Survey of Family Growth and found that almost 11 percent of American women had a history of treatment for pelvic inflammatory disease. They suggested that vaginal douching increased the risk of pelvic inflammatory disease by 50 percent among White and by 30 percent among African-American women.

FIGURE 1
Pelvic inflammatory disease and douching. Top: This figure represents the odds ratio and 95% confidence interval from several studies that looked at pelvic inflammatory disease and douching. Bottom: This figure represents the odds ratio and 95% confidence interval from several studies that looked at pelvic inflammatory disease and various frequencies of douching. *, estimated n = 231 based on two studies (10, 104).

Pelvic inflammatory disease is a prevalent problem worldwide as well as in the United States. Its serious reproductive outcomes and financial burdens are a major factor motivating sexually transmitted disease control and prevention. The weight of the evidence suggests strongly an association between pelvic inflammatory disease and douching. This association may represent the strongest incentive for policies to discourage women from douching.

REDUCED FERTILITY, INFERTILITY, AND ECTOPIC PREGNANCY

Pelvic inflammatory disease is a common cause of reduced fecundity (fertility) and sterility (112, 113). In an analysis of the 1995 National Survey of Family Growth, it was found that women with a history of pelvic inflammatory disease were less likely to be fecund compared with women with no such history (26). The likelihood of infertility increases as the number and severity of pelvic inflammatory disease episodes increase (26). It has been reported that 20 percent of women who have one episode of pelvic inflammatory disease will be infertile (114) and that 50 percent of women who have three or more episodes of pelvic inflammatory disease will be infertile (115). Vaginal douching may reduce fecundity by increasing susceptibility to infection (11). Baird et al. (11) found that women who douched were 30 percent less likely to become pregnant each month compared with women who did not douche. This risk was greater for younger women than it was for older women.

Ectopic pregnancy is defined as implantation of a fertilized egg outside the uterine cavity (116). Women with a history of pelvic inflammatory disease were twice as likely to have had an ectopic pregnancy compared with sexually active women who had no history of pelvic inflammatory disease (26). Vaginal douching has been associated with ectopic pregnancy (117-119). Several studies reported that vaginal douching increased the risk for ectopic pregnancy (figure 2) (3, 84, 120-123). Daling et al. (121) found that there was a small increase in risk of tubal pregnancy among women who douched more than two times per year in the past year (RR = 1.3, 95 percent CI: 0.9, 1.8). This risk was found to increase further if, in addition to douching more than two times per year, the women also had more than one sexual partner during their lifetime (RR = 1.6, 95 percent CI: 1.1, 2.3) or had previous exposure to chlamydia (RR = 2.4, 95 percent CI: 0.8, 7.3). Kendrick et al. (123) found that ectopic pregnancy risk among African-American women correlated with the number of years of douching at least once per month. They found that any douching carried some risk and that different douching strategies were associated with different levels of risk. In a case-control study that controlled for chlamydial exposure, J. M. Chow et al. (81) found that current douching was an independent risk factor for ectopic pregnancy. In a different study, W. H. Chow et al. (120) reported that the risk of tubal ectopic pregnancy for women who douched at least weekly was twice that of women who never douched. In a meta-analysis, Zhang et al. (3) found that frequent douching increased risk of ectopic pregnancy by 76 percent. In a meta-analysis of case-control and cohort studies done between 1978 and 1994, Ankum et al. (118) found only a slightly increased risk for ectopic pregnancy due to douching. However, in a case-control study of ectopic pregnancy with 69 cases and 101 controls, Phillips et al. (122) found that there was not a significant increase in the risk of ectopic pregnancy due to vaginal douching once or more per month (OR = 0.8, 95 percent CI: 0.3, 2.2).

FIGURE 2
Ectopic pregnancy and douching. Top: This figure represents the odds ratio and 95% confidence interval from several studies that looked at ectopic pregnancy and douching. Bottom: This figure represents the odds ratio and 95% confidence interval from several studies that looked at ectopic pregnancy and various frequencies of douching. *, estimated n = 1,000 based on five studies (81, 120-123).

Bacterial infections of the lower and upper genital tracts can result in pelvic inflammatory disease, which can, in turn, result in reduced fertility, infertility, and ectopic pregnancy. Many studies have looked at ectopic pregnancy risk and douching, with the majority of evidence finding an association. The temporal relation here remains problematic with the dearth of prospective studies.

CERVICAL CANCER

Cervical cancer is among the most common cancers in women worldwide (124). The American Cancer Society estimates that, during 2001, about 12,900 cases of invasive cervical cancer would be diagnosed in the United States and that about 4,400 American women would die from cervical cancer (125). Cervical cancer was once one of the most common causes of cancer death for American women but now, due to early detection and treatment, it is far less so (125). Worldwide, cervical cancer is the second or third most common cancer among women and, in some developing countries, it is the most common women's cancer (126). Nearly all squamous cell cervical cancer cases are related to human papillomavirus, a sexually transmitted infection. The cause of cervical cancer has been postulated to be multifactorial, with other cofactors being required to cause cancer. Haverkos et al. (127) proposed that tar exposure through tar-based vaginal douching products may be one such cofactor, increasing the risk of invasive cervical cancer. Cervical cancer is twice as high among African-American women as among White women, as are douching rates.

A positive relation between the frequency of douching and cervical cancer risk was found in several studies (figure 3)(3, 128-134). Graham and Schotz (128) found that, as the frequency of douching increased, so did the risk of invasive cervical cancer and carcinoma in situ. Peters et al. (129) found that the “frequency-years” of douching contributed independently and significantly to the risk of invasive cervical cancer. In a meta-analysis, Zhang et al. (3) found that douching was modestly associated with cervical cancer, when they aggregated studies that looked at both invasive cervical cancer and carcinoma in situ together or at invasive cervical cancer alone (RR = 1.25, 95 percent CI: 0.99, 1.59). However, it is unclear whether this risk ratio refers to invasive cervical cancer or both carcinoma in situ and invasive cervical cancer combined. Zhang et al. reported that, among women who douched at least once a week, the pooled adjusted risk ratio was 1.86 (95 percent CI: 1.29, 2.68). In a population-based case-control study in Utah, Gardner et al. (132) looked at a combined study group of invasive cervical cancer (13 percent of the study group) and carcinoma in situ (87 percent of the study group) and found no association between cervical cancer and douching in women who douched once per week or less. However, in women who douched more than once a week, a positive association was found (OR = 4.7, 95 percent CI: 1.9, 11). They hypothesized that douching alters the vaginal chemical environment, making the cervix more susceptible to pathologic changes and subsequent cervical cancer.

FIGURE 3
Cervical cancer and douching. Top: This figure represents the odds ratio and 95% confidence interval from several studies that looked at cervical cancer and douching. Middle: This figure represents the odds ratio and 95% confidence interval from several studies that looked at cervical cancer and various frequencies of douching. Bottom: This figure represents the odds ratio and 95% confidence interval from several studies that looked at cervical cancer and long durations of douching. CIS, carcinoma in situ; ICC, invasive cervical cancer. *, estimated n = 2,081 based on six studies (128-132, 134); †, error in original paper as to lower bound of 95% confidence interval: 0.8; our estimate of likely correct lower bound: 0.3.

In contrast, in a population-based case-control study in Costa Rica, Stone et al. (134) found that douching was not associated with carcinoma in situ or invasive cervical cancer. Herrero et al. (131), in a case-control study in Latin America, found no consistent association between vaginal douching and invasive cervical cancer. In a case-control study, Brinton et al. (130) found inconsistent results related to the risk of vaginal douching and invasive cervical cancer. They found 30-40 percent nonsignificant elevations in invasive cervical cancer risk associated with regular douching of five or more times per month, but they also found that nonregular douchers were at a higher risk than were regular douchers and that there was no clear relation to the age of first douching or total months of use. They therefore hypothesized that the association they observed may just represent chance.

Cervical cancer is a common cancer in women. Studies on cervical cancer and douching do not show a clear association, with some studies showing a positive association, some a negative association, and some no association. Although cervical cancer would not generate symptoms that might motivate a woman to douche, it is more common among women with other sexually transmitted disease risk factors. For a definitive assessment of causality, a prospective determination would be needed, a difficult task for a chronic disease with a long latency period.

HUMAN IMMUNODEFICIENCY VIRUS

Sexually transmitted diseases and other genital tract infections have been implicated in the acquisition and transmission of human immunodeficiency virus (135-137). Vaginal flora abnormalities, including bacterial vaginosis and sexually transmitted diseases, have been found to be associated with human immunodeficiency virus infection (138-140). Normal vaginal acidity can partly inactivate human immunodeficiency virus, so if bacterial vaginosis raises the pH of vaginal fluid and recruits target inflammatory cells, women with bacterial vaginosis may be more susceptible to human immunodeficiency virus. H2O2-producing lactobacilli have been shown to have viricidal effects on human immunodeficiency virus type 1 (141), and a low vaginal pH may reduce the number of human immunodeficiency virus type 1 target cells in the vagina (142). Helfgott et al. (143) found significant associations between human immunodeficiency virus and bacterial vaginosis, vulvovaginal candidiasis, and trichomonal vaginitis. In a study in Côte d'Ivoire, human immunodeficiency virus was found to be two times more frequent in women using intravaginal antiseptics (9). These cross-sectional studies could be confounded in that bacterial vaginosis, sexually transmitted diseases, and human immunodeficiency virus can be consequences of high risk sexual behavior, although several studies used logistic regression modeling to try to control for sexual behavior.

Not all douching products would be expected to carry comparable risks. Gresenguet et al. (86), in Bangui, Central African Republic, found that vaginal douching with noncommercial preparations was associated with an increased prevalence of human immunodeficiency virus, whereas douching with commercial antiseptic preparations was associated with a lower prevalence of this virus. However, the median years of education for women using commercial antiseptics was 8 years, compared with only 2 years for women using noncommercial preparations, so the results may be confounded by socioeconomic status. Tevi-Benissan et al. (144) reported that vaginal douching reduces semen load substantially after sexual intercourse, and they suggested douching as a supplementary means for prevention of heterosexual human immunodeficiency virus transmission. Given the associations of douching with bacterial vaginosis/sexually transmitted diseases, such a policy suggestion should be studied carefully as other data suggest douching to be harmful.

The relation among human immunodeficiency virus, bacterial vaginosis, and sexually transmitted diseases is complex, as all may be contributed to by high risk sexual behavior. Only a few cross-sectional studies have looked at human immunodeficiency virus and douching, suggesting concern that douching might be associated with risk for human immunodeficiency virus. Given the vast pool of women infected worldwide with human immunodeficiency virus, other sexually transmitted diseases, and bacterial vaginosis and the increased risk attributable to douching, education to discourage douching by women may have a huge impact on the risks of infections and reproductive health consequences.

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Part 2 of 2

DOUCHING FOR VAGINOSIS OR VAGINITIS

The near-universal medical view is that douching is not needed for routine vaginal hygiene (145). Monif (34) argues, however, that there is a role for douching among women with symptomatic vaginitis or vaginosis. Monif argues that douching is probably a behavioral response to an abnormal vaginal ecology, a factor not taken into account in cross-sectional studies, such that douching appears to be a cause when it is more likely to be a consequence. Monif (34) further argues that available microbiologic data indicate douching to be harmless. Separate studies by Monif et al. (33) and by Osborne and Wright (146) suggested a positive effect of douching, as in the case of using antibacterial douches to replace systemic antibiotics during vaginally related surgery. Monif et al. (33) found that a povidone-iodine douche produced a dramatic fall in the total bacteria in the vagina for the first 10 minutes following administration. Within 2 hours, near baseline counts were reestablished, suggesting a benign nature of single episode douching.

Three vinegar-containing douches tested by Pavlova and Tao (30) were selectively inhibitory against vaginal pathogens associated with bacterial vaginosis, group B streptococcal vaginitis, and candidiasis, but not lactobacilli, giving a preliminary suggestion that vinegar douches could be beneficial for treating some vaginal infections. Beaton et al. (147) found that, in women with minor vaginal irritation of unknown etiology, short-term use of a medicated povidone-iodine douche preparation resulted in improvement of symptoms, including discharge, odor, pruritus, erythema, burning, and discomfort; 94 percent of the 185 patient complaints were cleared completely. They found that 98 percent of the patients responded favorably to the douche, with no adverse effects reported. Manzardo et al. (148) found that a tetridamine vaginal lavage, twice daily for 7 days, reduced or eliminated all inflammation symptoms such as burning and leucorrhea in women with vulvovaginitis and cervicitis.

In a 1997 meeting of the Nonprescription Drug Advisory Committee of the Food and Drug Administration (149), Dr. Andrew Onderdonk presented data looking at women with abnormal vaginal ecology, such as women with culture-positive vaginal yeast infections (32). His group treated women with either sterile water, a vinegar and water douching solution, or a povidone-iodine solution. Twenty-four hours after treatment with the various douche solutions, the only women whose vaginal microflora returned to normal were the women who used the povidone-iodine douche. This suggested that, in women who have an abnormal vaginal ecology, perhaps due to a vaginal yeast infection, douching with povidone-iodine may be beneficial and may help to return the vaginal ecology back to normal values. Testing this concept in a controlled clinical trial is problematic, however, given the known risks of douching. It is unlikely that a peer review committee or a research ethics board would see merit in deliberately allocating women to a “douching encouraged” group.

Nonpregnant women who are symptomatic may derive some benefit from vaginal douching, specifically with povidone-iodine, if they have abnormal vaginal ecology. However, given the many studies that have suggested adverse effects from douching compared with the very few studies that have shown a potential benefit, douching cannot be a recommended therapy and is surely not indicated for routine vaginal “hygiene.”

INTRAPARTUM OR ROUTINE HYGIENIC DOUCHING

Douching has also been used in pregnant women in labor. Stray-Pedersen et al. (150) found that intrapartum vaginal douching with 0.2 percent chlorhexidine significantly reduced mother-to-child transmission of vaginal microorganisms, such as Streptococcus agalactiae, and both maternal and early neonatal infectious morbidity. Dykes et al. (151) found that a single washing of the urogenital tract with 0.5 g of chlorhexidine per liter in women who were carriers of group B streptococci in weeks 38-40 of pregnancy resulted in a suppression of the number of colony-forming units of group B streptococci. However, Sweeten et al. (152) found that a one-time 0.4 percent chlorhexidine vaginal wash in laboring pregnant women did not decrease the incidence of infectious morbidity in parturients, as compared with the use of sterile water. Taha et al. (153) noted reduced maternal and newborn sepsis rates postpartum with use of an intrapartum 0.2 percent vaginal chlorhexidine wash. Neither Gaillard et al. (154) nor Biggar et al. (155) found vaginal lavage ranging from 0.2 to 0.4 percent chlorhexidine to be protective for mother-to-child human immunodeficiency virus transmission. The above studies in pregnant women look primarily at one time douching that has little to do with typical, repetitive use of douching for hygienic reasons. However, limited vaginal lavage has utility in transient reduction of pathogenic vaginal organisms intrapartum.

Women without vaginal symptoms primarily douche for perceived hygienic or aesthetic benefit. Postcoital douching has been suggested for two purposes, reducing semen exposure to prevent pregnancy and to prevent human immunodeficiency virus transmission. After sexual intercourse, semen increases the pH of the vagina that facilitates sperm motility (144). Douching can dilute and wash out semen and can help return the vagina to its normal acidity, theoretically helping to prevent heterosexual human immunodeficiency virus transmission. Obaidullah (156) found that women who used a Betadine Vaginal Cleansing Kit before and after insertion of an intrauterine contraceptive device showed a marked absence of bacterial growth 4-6 weeks later, compared with control volunteers who used no cleansing agents. The investigators speculated that an absence of bacterial growth in the study group could help to minimize the risk of intrauterine device-related pelvic infection. These speculations and highly limited data do not, however, suggest that douching can be advocated for women. One could just as easily speculate that douching increases human immunodeficiency virus risk, increases pregnancy risk (by pressure forcing sperm into the endocervical canal, for instance), or exacerbates intrauterine device-related risks.

Despite a few dissenting views, the preponderance of the evidence suggests that douching is not necessary or beneficial and is very likely to be harmful (2-4, 6, 157-161). Multiple case reports indicate occasional very serious douching-related harm. Safran and Braverman (162) found that douching daily with polyvinylpyrrolidone-iodine for 14 days resulted in a significant increase in serum total iodine concentration and urine iodine excretion, followed by an increase in serum thyrotropin, although never above the normal range. They concluded that iodine is absorbed across the vaginal mucosa and that the subsequent increase in serum total iodine causes subtle increases in serum thyrotropin but with no overt hypothyroidism. Udoma et al. (163) reported a rectovaginal fistula following coitus in a woman in Nigeria after douching with aluminum potassium sulfate dodecahydrate (potassium alum) prior to intercourse. Vaginal douching with a bulb syringe or effervescent fluid has been reported as a cause of asymptomatic, spontaneous pneumoperitoneum (157, 164).

MEDICAL AND PUBLIC HEALTH ORGANIZATIONS AND DOUCHING

There is no official medical or public health advisory policy on whether douching should be discouraged. In January 2001, various medical organizations were contacted via e-mail and their Web sites were searched for information pertaining to vaginal douching. The following organizations replied that they have no official policy statements or positions on the use of vaginal douche products: the American College of Nurse-Midwives, the American College of Obstetricians and Gynecologists, the American Medical Association, the American Medical Women's Association, the American Public Health Association, the Centers for Disease Control and Prevention, the Food and Drug Administration, the National Institute of Allergy and Infectious Diseases, the National Institute of Child Health and Human Development, the National Institute of Environmental Health Sciences, the National Institutes of Health, and the World Health Organization.

An American College of Obstetricians and Gynecologists' technical bulletin (165) states that vaginitis occurs when the vaginal ecosystem is altered, which can result from several factors including repeated douching. The rationale presented in the bulletin is that repeated douching may alter the pH level or suppress growth of normal, endogenous bacteria, leading to vaginitis. A vaginitis information sheet by the American Medical Association (166) states that, in women of childbearing age, vaginitis can be caused by frequent douching. They state that women of all ages can get vaginitis from chemical irritation or an allergic reaction from vaginal douches. The Centers for Disease Control and Prevention (167) state that, in a study of African-American women, an association has been found between the length of time women douched and their risk of developing ectopic pregnancy. The Centers for Disease Control and Prevention (168) have a bacterial vaginosis fact sheet stating that women are at an increased risk for bacterial vaginosis if they douche, because douching upsets the normal balance of vaginal bacteria, and that not douching can lower a woman's risk of developing bacterial vaginosis. In a Morbidity and Mortality Weekly Report article (169) on pelvic inflammatory disease, douching was suggested as a risk factor for pelvic inflammatory disease, but the Centers for Disease Control and Prevention stated that the data (as of 1991) did not provide enough information to determine if the positive associations were due to the characteristics of the women who douche or to the douching itself. The Centers for Disease Control and Prevention authors found that no definitive conclusion could be reached regarding the relation between douching and pelvic inflammatory disease. A Centers for Disease Control and Prevention manual on family planning in Africa cautions against douching as follows: “Douching is unnecessary to maintain vaginal hygiene. Moreover, douching is associated with an increased risk for pelvic inflammatory disease and ectopic pregnancy. Pregnant women especially should be warned about the risks associated with douching”(170, p. 195).

The National Institute of Allergy and Infectious Diseases (171) provides a health information sheet on vaginitis that states that douching may cause vaginal irritation and vaginitis. The National Institute of Environmental Health Sciences and the National Institutes of Health both reference press releases on a study by Dr. Donna Day Baird and colleagues that found a dose-response reduction in fertility with increased douching (172). The National Institute of Allergy and Infectious Diseases (173) has a fact sheet on pelvic inflammatory disease that states that women who douche one or two times a month may be more likely to have pelvic inflammatory disease than those who douche less than once a month. Their fact sheet on sexually transmitted diseases states that, to prevent sexually transmitted diseases, sexually active women should avoid douching because douching removes some of the normal protective bacteria in the vagina and increases the risk of getting some sexually transmitted diseases (174). The fact sheet on vaginal yeast infections (vulvovaginal candidiasis) states that douching may increase the incidence of yeast infections (175). The National Women's Health Information Center (176) has an information sheet specifically on douching, stating that douching makes women more susceptible to bacterial infections and spreads existing infections into the upper reproductive tract. The National Women's Health Information Center claims that women who douche have increased bacterial vaginosis, sexually transmitted diseases, and pelvic inflammatory disease; that douching does not prevent pregnancy but may decrease fertility; and that douching increases the risk of low birth weight babies and ectopic pregnancy. They also state that the safest way to clean the vagina is to let the vagina clean itself, which it does by secreting mucus. Their final recommendation was that, if a woman has vaginal discharge, she should seek medical attention without first douching because washing away the discharge makes it harder to identify the infection. The Surgeon General's office responded to our douching-related queries by referring us to the American College of Obstetricians and Gynecologists and the Association of Professors of Gynecology and Obstetrics. Although informative fact sheets discourage douching, none of the governmental or private organizations that we contacted has an official position statement that either advocates or discourages douching.

On April 15, 1997, the Nonprescription Drug Advisory Committee of the Food and Drug Administration held a meeting to discuss vaginal douching (149). Presentations came from the Food and Drug Administration, the Nonprescription Drug Manufacturers Association, and the Purdue Frederick Company (manufacturer of Betadine medicated douche), among others. The Committee concluded that there was not enough information to determine that a causal relation existed between douching and its adverse outcomes. More research was recommended, and the Food and Drug Administration was urged to look into federal regulation and better product labels. The Committee found that some of the studies had residual confounding due to sexual behavior and underreporting of sexually transmitted diseases. A key point in this argument was that, without determining a temporal relation, the studies so far have not been able to tell which came first, douching or the adverse outcome (sexually transmitted diseases, pelvic inflammatory disease, infection), when douching may be undertaken as a way to treat the symptoms of the disease. A representative from the National Women's Health Network stated that douching had no benefit on women's health and enhanced the chances of developing upper reproductive tract infections, pelvic inflammatory disease, ectopic pregnancy, and infertility. A representative from the Food and Drug Administration's Division of Over-the-Counter Drug Evaluation stated that the Agency considers vaginal douches to be both drugs (because they are sometimes used to treat disease) and cosmetics (because they cleanse and/or scent part of the body). From the Food and Drug Administration's review of epidemiologic studies on vaginal douching (considered published case-control and cross-sectional studies), a consistent moderate adverse or null effect of douching was noted; the evidence was considered suggestive that douching independently raises the risk of pelvic inflammatory disease, ectopic pregnancy, infertility, and cervical carcinoma.

FUTURE DIRECTIONS AND CONCLUSIONS

The present review suggests that future studies must assess more directly the extent to which douching is a causal factor in diseases such as pelvic inflammatory disease and bacterial vaginosis, or if douching is merely a behavior that is more common among women who are at risk of sexually transmitted diseases and/or that douching is done in response to symptoms (15). The effects of different solutions and devices must be considered in more detail. Perhaps there are adverse effects associated with douching if only certain solutions are used but less or no harm with other solutions.

The weight of the evidence today suggests that stronger regulations for vaginal douche products may be indicated, including ingredient control, clearer labeling, and a required statement on product advertisements and on the products themselves that douche products have no proven medical value and may be harmful. A prospective cohort study or, if serious ethical concerns can be resolved, a randomized clinical trial may address these questions. A randomized “community” trial could be considered, where the communities studied are a large group of people from the same area, such as a college or a city. They could be assigned at random to treatment and no treatment, where the treatment group would receive an educational program regarding the potential dangers associated with douching and the women would be encouraged to not douche. Douching prevalence and sexually transmitted disease rates could be assessed before the educational program and at regular intervals during the program. The no treatment group, receiving no such educational intervention, would be assessed in a similar way. The study endpoint could compare rates of douching and sexually transmitted diseases. However, because motivational factors for douching are individualized and often women strongly feel the need to douche, the educational program may not influence enough women to stop douching, affecting the statistical power of such a study. Feasibility and cost may be prohibitive, in which case we may continue in our present state of knowledge/ignorance.

It is accepted that pregnant women should avoid douching. Intrapartum vaginal antiseptic lavage can be highly beneficial, but this is a completely different irrigation event than repetitive vaginal douching. There are limited data that suggest that douching in symptomatic women may have some utility. The preponderance of evidence shows an association between douching and numerous adverse outcomes. Most women douche for hygienic reasons; it can be stated with present knowledge that routine douching is not necessary to maintain vaginal hygiene; again, the preponderance of evidence suggests that douching may be harmful. The authors of the present review believe that there is no reason to recommend that any woman douche and, furthermore, that women should be discouraged from douching.

Many women douche, especially African Americans. Because the population-level health risks attributable to this common practice could be very large if douching predisposes to even a fraction of the disease burden discussed in this review, the potential salutary impact of reducing douching activity is substantial. Intervention studies may be the very best way to gain both health benefit and insight into the temporal associations of douching and adverse outcomes. We also believe that responsible government, health, and professional organizations should reexamine available data and determine if there is enough information to issue clear policy statements on douching. We believe that, when they conduct such reviews, they will conclude, with us, that since there are no demonstrated benefits to douching and considerable evidence of harm, women should be encouraged to not douche.

ACKNOWLEDGMENTS

This work was supported by National Institutes of Health grant U19 AI-38514 (University of Alabama at Birmingham Sexually Transmitted Disease Cooperative Research Center, E. Hook III, Principal Investigator) and the University of Alabama at Birmingham Medical Scientist Training Program.

The authors thank Ellen Funkhouser and M. Kim Oh for discussion and comments.

Abbreviations

CI confidence interval
OR odds ratio
RR risk ratio

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Alan Frank Guttmacher
by Wikipedia
Accessed: 4/1/20


Alan Frank Guttmacher
President of Planned Parenthood
In office: June 20, 1962 – April 13, 1968
Preceded by: Margaret Sanger
Personal details
Born: May 19, 1898
Died: March 18, 1974

-- Alan F. Guttmacher Planned Parenthood interview, 1968

Alan Frank Guttmacher (19 May 1898 – 18 March 1974), was an American obstetrician/gynecologist. He served as president of Planned Parenthood and vice-president of the American Eugenics Society.[1] Dr. Guttmacher founded the American Association of Planned Parenthood Physicians, now known as the Association of Reproductive Health Professionals, as a forum for physicians to discuss the birth control pill and other advances in the field. He founded the Association for the Study of Abortion in 1964. He was a member of the Association for Voluntary Sterilization. The Guttmacher Institute is named after him.

In 1973, Guttmacher was one of the signers of the Humanist Manifesto II.[2]

Family

Alan Guttmacher was born in 1898 to Rabbi Adolf (Adolph) Guttmacher, and Laura (Oppenheimer) Guttmacher, German Jewish emigrants. His twin brother, Manfred Guttmacher, was an advisor to the Baltimore City's Supreme Bench as a psychiatrist. Their older sister, Dorothy Emma Guttmacher, owned the Tudor Flower Shops at Johns Hopkins Hospital. Alan married Leonore Gidding in 1926 and together they raised three daughters, Ann (Loeb), Sally (Holtzman), and Susan (Green).

Professional history

Guttmacher was a graduate of Johns Hopkins University and the Hopkins Medical School. He served as Director of Obstetrics and Gynecology and was appointed Obstetrician and Gynecologist-In-Chief at Mount Sinai Hospital in New York for approximately ten years. In 1962, ten years after moving to New York, he became president of the Planned Parenthood Federation. He extended this endeavor by founding the Association of Planned Parenthood Physicians which included scientists and medical practitioners. From 1964–1968, he served as Chairman of the Medical Committee of the International Planned Parenthood Federation. Guttmacher was also a fellow of the American College of Obstetrics and Gynecologists, the American Fertility Society, New York Academy of Medicine, and the American Association of Obstetricians and Gynecologists.[3]

References

1. Franks, Angela (2005). Margaret Sanger's Eugenic Legacy. McFarland & Company. p. 76. ISBN 978-0-7864-2011-7.
2. "Humanist Manifesto II". American Humanist Association. Archived from the original on October 20, 2012. Retrieved October 9, 2012.
3. "Dr. Alan Guttmacher dies." The Baltimore Sun. 19 March 1974.

External links

• "Who was Alan Guttmacher?" (from the Guttmacher Institute)
• Alan F. Guttmacher papers, 1860, 1898-1974. H MS c 155. Harvard Medical Library, Francis A. Countway Library of Medicine, Boston, Mass.

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Alan Guttmacher, Pioneer In Family Planning, Dies
by Alden Whitman
New York Times
March 19, 1974

Dr. Alan F. Guttmacher, a pioneer and international leader in family planning, died yesterday of leukemia at the Mount Sinai Hospital. He was 75 years old and lived at 1185 Park Avenue.

Since 1962, Dr. Guttmacher had been president of the Planned Parenthood Federation of America. Previously, while actively advocating freedom of choice in the bearing of children, he practiced as a gynecologist and obstetrician.

Widely regarded as the elder statesman of the birth‐control movement, Dr. Guttmacher advocated not only unrestricted’ access to contraceptive information, but also liberal abortion regulations. “What Dr. Guttmacher sought,” a colleague said yesterday, “was to assure women the right to plan their whole lives, including when and if to bear children.”

Apart from his medical practice and his duties as chairman of the department of obstetrics and gynecology at Mount Sinai, which he relinquished in 1962, Dr. Guttmacher spent the bulk of his time as a birth‐control lecturer and as an expert witness before legislative bodies.

His approach to birth control was often earthy. “When you give the kids the keys to your car,” he once told a Los Angeles group, “be sure to give them contraceptives, too.”

Constantly on the Go

To many people Dr. Guttmacher seemed to be an evangelist. He traveled constantly, speaking pungently to any audience that could be assembled. He carried contraceptives for distribution in Africa. He helped raise and deliver money for birth‐control clinics in Pakistan. His vigor and his zeal astounded his friends while they confounded his opponents and critics, who included the Roman Catholic clergy and number of physicians and social planners.

Dr.'Guttmacher also had his critics in the birth‐control movement, who contended that he liked to travel and to hear the sound of his own voice: “Alan is the third most egotistical man I ever met, colleague said a couple of years ago, adding:

“But I don't mean this disparagingly. He just enjoys being Alan Guttmacher—and he's good at it.”

To most of his associates, however, Dr. Guttmacher was, in the words of one who worked closely with him for many years, “incandescent — a man with flavor, sensitivity and conviction.”

In the birth‐control movement Dr. Guttmacher was firmly on the side of voluntarism as opposed to some demographers who urged coercive methods to halt population growth.

In Middle of Change

“Alan came into the movement when it was a medical concern focused on the individual and family,” according to Dr. Christopher Tietze of the Population Council. “But the emphasis is shifting to a demographic concern for survival.”

Although Dr. Guttmacher was aware of the new trend, he believed compulsory birth control morally indefensible as well as impractical. “Just who is going to round up 200 million Latin‐American men and sterilize them?” he once asked. He contended that a woman should have as many children as she wants, but not more than she could provide for Freedoin to choose was his basic approach.

An accessible and friendly man, he rarely stood on ceremony. Visitors were soon on first‐name basis with him. And his enthusiasm was such that those he met casually were often drawn into some aspect of his cause.

Dr. Guttmacher was an erect and agile person, who played tennis until a few years ago and who loved to walk at brisk clip. He had little use for executive trappings or for eating fancy lunches. A cup of bouillon and a bowl of cottage cheese, eaten at his desk, was his usual fare; his guests were obliged to subsist on a delicatessen sandwich.

Had Framed Cushing Letter

His office was filled with family photographs or paintings that suggested to many visitors that Dr. Guttmacher's forebears had not practiced birth control. There was also a ceramic figure of an Indonesian fertility goodess with nine babies clinging to it On the wall, too, was a framed letter from the late Richard Cardinal Cushing of Boston that said:

“Don't worry about my attitude toward the cause in which you are interested. In due time I will make a statement that is in harmony with the teachings of the faith I profess.”

The statement was considered liberal and an important factor in the repeal of restrictive birth‐control laws in Massachusetts.

Alan Frank Guttmacher was born in Baltimore on May 19, 1898, the son of Rabbi Adolf Guttmacher and the former Laura Guggenheimer. He attended the Johns Hopkins University and later its School of Medicine, from which he took his degree in 1923. After residency in obstetrics and gynecology at the Johns Hopkins Hospital and at Mount Sinai, he returned to Baltimore tol practice and teach.

His professional standing was formidable. He was professor of obstetrics at the Johns Hopkins Medical School, chief in obstetrics at Sinai Hospital in Baltimore, clinical professor of obstetrics and gynecology at Columbia University's College of Physicians and Surgeons, special lecturer in maternal and child health at Harvard; and, from 1952 to 1962, director of Mount Sinai's department of obstetrics and gynecology.

In the early years of Dr. Guttmacher's practice and advocacy of birth control he was often mistaken for his identical twin, Dr. Manfred Guttmacher, a psychiatrist and also a birthcontrol proponent, who died in 1967. Patients frequently went to the wrong office by mistake, and there were occasions, when for fun, the brothers answered to each other's names.

Alan Guttmacher's interest in birth control began in the early nineteen‐thirties in Baltimore. The beliefs he developed then were little changed throughout his life — that it is a basic human right for every woman to choose whether she wants children; and that abortion should be a question for phyicians. to decide, not law en He also adopted the view that the poor should have the same access to birth‐control information as the wealthy. His strong and public advocacy of these attitudes won him the friendship of H. L. Mencken, the Baltimore sage, and the furious resentment of much of the city's medical and social establishment.

When Dr. Guttmacher moved to New York. in 1952 and began to achieve national and international prominence, he was generally regarded as the successor to Margaret Sanger, the pioneer birth‐control crusader in the United ‘States.

Backed Lippes Loop

As an advocate, he took stands that a number of his physician colleagues thought unwise. For example, he supported use of the Lippes Loop, a contraceptive intrauterine de. vice that is still widely used here and in many underdeveloped countries.

“The thing you've got to realize is that the Loop was once discredited,” Dr. Tietze said. “But it was obvious that the pill was getting nowhere in the poor countries—you have to know how to count to use it, and the majority of village women in the Far East can't do this; something else had to be tried and Alan decided the I.U.D.'s ought to have another chance.”

These devices have their limitations, according to specialists, but they are better than no birth‐control devices in many instances.

Dr. Guttmacher also tended to play down and put in perspective the side effects of birth‐control pills, despite evidence in some instances that such pills can lead especially to problems of blood clotting in women. More cautious physicians felt that Dr. Guttmacher had not emphasized sufficiently the dangers of the pills.

Among Dr. Guttmacher's books, three were usually singled out as most influential—“Birth Control and Love,” “Understanding Sex” and “Pregnancy, Birth and Family Planning.” These were books for laymen.

Dr. Guttmacher leaves his wife, the former Leonore Lidding; three daughters, Mrs. Ann Loeb, Mrs. Susan Green and Mrs. Sally Holtzman; and two grandchildren.

There will be a private funeral. A memorial service will be held later.

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Planned Parenthood’s Century of Brutality
by Kevin D. Williamson
National Review
June 19, 2017 8:00 AM

It is functioning today as its eugenics-obsessed founders intended.

Infanticide did not go out of fashion with the advance from savagery to barbarism and civilization. Rather, it became, as in Greece and Rome, a recognized custom with advocates among leaders of thought and action.

— Margaret Sanger, Woman and the New Race

Clarence C. Little was a cultivated man. He was a Harvard graduate who served as president of the University of Maine and the University of Michigan. He was one of the nation’s leading genetics researchers, with a particular interest in cancer. He was managing director of the American Society for the Control of Cancer, later known (in the interest of verbal economy) as the American Cancer Society; the president of the American Eugenics Society, later known (in the interest of not talking about eugenics) as the Society for Biodemography and Social Biology; and a founding board member of the American Birth Control League, today known (in the interest of euphemism) as Planned Parenthood. His record as a scientist is not exactly unblemished — he will long be remembered as the man who insisted that “there is no demonstrated causal relationship between smoking or [sic] any disease” — but he was the very picture of the socially conscious man of science, without whom the National Cancer Institute, among other important bodies, probably would not exist.

He was a humane man with horrifying opinions.

Little is one of the early figures in Planned Parenthood whose public pronouncements, along with those of its charismatic foundress, Margaret Sanger, often are pointed to as evidence of the organization’s racist origins. (Students at the University of Michigan are, at the time of this writing, petitioning to have his name stripped from a campus building.) Little believed that birth-control policy should be constructed in such a way as to protect “Yankee stock” — referred to in Sanger’s own work as “unmixed native white parentage,” if Little’s term is not clear enough — from being overwhelmed by what was at the time perceived as the dysgenic fecundity of African Americans, Catholic immigrants, and other undesirables. (“The feebleminded are notoriously prolific in reproduction,” Sanger reported in Woman and the New Race.) The question of racial differences was an obsession of Little’s that went well beyond his interest in eugenics and followed him to the end of his life; one of his later scientific works was “The Possible Relation of Genetics to Differences in Negro–White Mortality Rates from Cancer,” published in the 1960s.

The birth-control movement of the Progressive era is where crude racism met its genteel intellectual cousin: Birth Control Review, the in-house journal of Planned Parenthood’s predecessor organization, published a review, by the socialist intellectual Havelock Ellis, of Lothrop Stoddard’s The Rising Tide of Color against White World Supremacy. Ellis was an important figure in Sanger’s intellectual development and wrote the introduction to her Woman and the New Race; Stoddard was a popular birth-control advocate whose intellectual contributions included lending to the Nazi racial theorists the term “untermensch” as well as developing a great deal of their theoretical framework: He fretted about “imperfectly Nordicized Alpines” and such. Like the other eugenics-minded progressives of his time, he saw birth control and immigration as inescapably linked issues.

Stoddard’s views were so ordinary a part of the mainstream of American intellectual discourse at the time that F. Scott Fitzgerald could refer to his work in The Great Gatsby without fearing that general readers would be mystified by the reference. What did Stoddard want? “We want above all things,” he wrote,

to preserve America. But “America,” as we have already seen, is not a mere geographical expression; it is a nation, whose foundations were laid over three hundred years ago by Anglo-Saxon Nordics, and whose nationhood is due almost exclusively to people of North European stock — not only the old colonists and their descendants but also many millions of North Europeans who have entered the country since colonial times and who have for the most part been thoroughly assimilated. Despite the recent influx of alien elements, therefore, the American people is still predominantly a blend of closely related North European strains, and the fabric of American life is fundamentally their creation.

Yesterday’s scientific progressives are today’s romantic reactionaries.

Sanger, who believed that the potential for high civilization resided within “the cell plasms” of individual humans, made statements that were substantially similar: “If we are to develop in America a new race with a racial soul, we must keep the birth rate within the scope of our ability to understand as well as to educate. We must not encourage reproduction beyond our capacity to assimilate our numbers so as to make the coming generation into such physically fit, mentally capable, socially alert individuals as are the ideal of a democracy.”

Such was the intellectual ferment out of which rose the American birth-control movement — or, rather, the American birth-control movements, of which there were really two. Sanger, working within the socialist–feminist alliance of her time, was a self-styled radical who published a short-lived journal called “The Woman Rebel,” the aim of which as described in its inaugural issue was “to stimulate working women to think for themselves and to build up a conscious fighting character.” To fight what? “Slavery through motherhood.” The Post Office refused to circulate the periodical, a fact that The Woman Rebel reported with glee: “The woman rebel feels proud the post office authorities did not approve of her. She shall blush with shame if ever she be approved of by officialism or ‘comstockism.’” But Sanger and her clique did not have a monopoly on the birth-control market. Her rival was Mary Ware Dennett, founder of — see if this name sounds familiar — the Voluntary Parenthood League (VPL).

Where Sanger was a radical, Dennett was a liberal, couching her advocacy in the familiar language of the American civil-libertarian tradition. She was an ally of the American Civil Liberties Union, which had defended her when she was charged with distributing birth-control literature classified (as most of it was at the time) as “obscene.” While Sanger’s organization was focused on setting up birth-control clinics (the first was in Brooklyn), Dennett’s group was focused on lobbying Congress for the legalization of contraception. Sanger’s group was characterized by a top-down management structure (the local affiliates had no say in American Birth Control League policymaking) and a cash-on-the-barrelhead approach to social reform: Its membership and coffers were swelled in no small part by the fact that the ABCL [American Birth Control League] would not provide birth-control literature to anyone who was not a dues-paying member.

As Linda Gordon put it in The Moral Property of Woman: A History of Birth-Control Politics:

Increasingly the ABCL organized its local affiliates as upper-class women’s clubs, even high-society charity groups. In 1926, league organizing in Philadelphia was focused mainly on women of the Main Line, a group of extremely wealthy suburbs. In Grand Rapids, Michigan, Mrs. C. C. Edmonds, of 1414 Wealthy St., S.E., was collecting “influential people” for a local group. New York meetings were held in the Bryn Mawr Club. These details pile up, drawing an unmistakable picture of an organization of privileged women.

In the contest between the ABCL and VPL, we see the familiar struggle that has long characterized the broader American Left: On one hand, there are liberals advocating a legislative reform project through ordinary democratic means; on the other hand are progressives, often led by radicals, who are engaged in a social-change project based on coopting institutions and the expertise and prestige associated with them. Gordon concludes: “It was Sanger’s courting of doctors and eugenists that moved the ABCL away from both the Left and liberalism, away from both socialist-feminist impulses and civil liberties arguments toward an integrated population ‘program for the whole society.’”

Which is to say, the word “planned” in “Planned Parenthood” can be understood to function as it does in the other great progressive dream of the time: “planned economy.”

Who plans for whom?

Sanger herself was generally careful to forswear compulsion in her eugenics program, but in reality the period was characterized by the widespread use of involuntary sterilization. Mandatory-sterilization bills were introduced unsuccessfully in Michigan and Pennsylvania at the end of the 19th century, but in 1907 Indiana became the first of many states to create eugenics-oriented sterilization programs, targeting such “unfit” populations as criminals and the mentally ill, along with African Americans (60 percent of the black mothers at one Mississippi hospital were involuntarily sterilized) and other minority groups. The Oregon state eugenics board was renamed but was not disbanded until the 1980s. About 65,000 people in the United States were involuntarily sterilized.

European programs went even further, with the Swiss experiment in involuntary sterilization drawing the attention of Havelock Ellis, who wrote up his views in “The Sterilization of the Unfit.” Ellis, too, objected to compulsory measures — up to a point. “There will be time to invoke compulsion and the law,” he wrote, “when sound knowledge has become universal, and when we are quite sure that those who refuse to act in accordance with sound knowledge refuse deliberately.” He did not have access to the modern progressive term “denialist,” but the argument is familiar: Once the science is settled, then the state is empowered to act on it through whatever coercive means are necessary to achieve the end. Two recent press releases from the pro-abortion Guttmacher Institute, both from May, are headlined: “State Abortion Restrictions Flying in the Face of Science” and “Many Abortion Restrictions Have No Rigorous Scientific Basis.”

Progressives frequently talked about eugenics in zoological terms, but, in the main, eugenics was subordinated to the larger progressive economic agenda: the management of productive activity by enlightened experts.

Progressives holding views closer to those of the proto-Nazi Lothrop Stoddard frequently talked about eugenics in zoological terms, but, in the main, eugenics was subordinated to the larger progressive economic agenda: the management of productive activity by enlightened experts. The great economic terrors among progressives of the time were “overproduction” and “destructive competition,” both of which were thought to put downward pressure on wages, profits, and, subsequently, standards of living. Contraception was widely understood as a political solution to a supply-and-demand problem, with birth control understood as one element in a broad and unified program of economic control. Ellis sums up this view in his foreword to Sanger’s Woman and the New Race:

The modern Woman Movement, like the modern Labour Movement, may be said to have begun in the Eighteenth century. The Labour movement arose out of the Industrial Revolution with its resultant tendency to over-population, to unrestricted competition, to social misery and disorder. The Woman Movement appeared as an at first neglected by-product of the French Revolution with its impulses of general human expansion, of freedom and of equality. . . . Woman, by virtue of motherhood, is the regulator of the birthrate, the sacred disposer of human production. It is in the deliberate restraint and measurement of human production that the fundamental problems of the family, the nation, the whole brotherhood of mankind find their solution. The health and longevity of the individual, the economic welfare of the workers, the general level of culture of the community, the possibility of abolishing from the world the desolating scourge of war — all these like great human needs, depend, primarily and fundamentally, on the wise limitation of the human output.

Or, as Sanger insisted: “War, famine, poverty, and oppression of the workers will continue while woman makes life cheap.”

There is more to this history than exegesis of Progressive-era thinking. It is significant that Sanger’s birth-control movement, and not Dennett’s, came to dominate the field. The financially driven structure of local affiliates working in complete subordination to a tightly controlled national body of course survives in the modern iteration of Planned Parenthood, but, more important, so does the humans-as-widgets conception of sexuality and family life. The eugenic habit of mind very much endures, though it is less frequently spoken of plainly.

In his Buck v. Bell decision — confirming that involuntary-sterilization programs pass constitutional muster “for the protection and health of the state” — the great humanist Oliver Wendell Holmes Jr. declared: “Three generations of imbeciles are enough.” Never having been overturned, Buck remains, in theory, the law of the land. But that was long ago. And yet: Justice Ruth Bader Ginsburg, a reliable supporter of abortion rights, has described Roe v. Wade as being a decision about population control, “particularly growth in populations that we don’t want to have too many of.” Like Ellis and Sanger, Ginsburg worries that, without government intervention, birth control will be disproportionately practiced by the well-off and not by the members of those “populations that we don’t want to have too many of.” In an interview with Elle, Ginsburg said, “It makes no sense as a national policy to promote birth only among poor people.” That wasn’t 1927 — it was 2014. A co-counsel for the winning side of Roe v. Wade, Ron Weddington, advised President Bill Clinton that an expanded national birth-control policy incorporating ready access to pharmaceutical abortifacients promised immediate benefits: “You can start immediately to eliminate the barely educated, unhealthy, and poor segment of our country. It’s what we all know is true, but we only whisper it.”

Justice Ruth Bader Ginsburg, a reliable supporter of abortion rights, has described Roe v. Wade as being a decision about population control, ‘particularly growth in populations that we don’t want to have too many of.’

But it is not true that we only whisper it. In Freakonomics, one of the most popular economics books of recent years, Steven D. Levitt and Stephen J. Dubner argued that abortion has measureable eugenic effects through reduction in crime rates. Of course that debate has an inescapable racial aspect: “Fertility declines for black women are three times greater than for whites (12 percent compared with 4 percent). Given that homicide rates of black youths are roughly nine times higher than those of white youths, racial differences in the fertility effects of abortion are likely to translate into greater homicide reductions,” Levitt and a different co-author had written in a paper that the book drew from. Whatever the merits of this argument, it is very much in line with the classical progressive case for birth control, which was developed as a national breed-improvement project rather than one of individual women’s choices. Linda Gordon notes: “A content analysis of the Birth Control Review showed that by the late 1920s only 4.9 percent of its articles in that decade had any concern with women’s self-determination.”

The American Birth Control League was founded by Margaret Sanger in 1921, working out of office space provided by the American Eugenics Society. Sanger would depart seven years later as part of a factional dispute, with various elements of her organization eventually reunited in 1939 as the Birth Control Federation of America. But the words “birth control” at that time were considered public-relations poison, and so in 1942 the organization was renamed the Planned Parenthood Federation of America.

Sanger herself often wrote critically about abortion, which, especially early in her career, she classified alongside infanticide, offering contraception as the obvious rational alternative to such savagery. Her arguments will sound at least partly familiar to modern ears: “Do we want the millions of abortions performed annually to be multiplied? Do we want the precious, tender qualities of womanhood, so much needed for our racial development, to perish in these sordid, abnormal experiences?” But that line of thinking was not destined to endure, and by the 1950s Planned Parenthood was working for the liberalization of abortion laws. Sanger’s successor, obstetrician Alan Frank Guttmacher, also served as vice president of the American Eugenics Society and was a signer of the second “Humanist Manifesto,” which called for the worldwide recognition of the right to birth control and abortion and, harkening back to the 1920s progressives, the extension of “economic assistance, including birth control techniques, to the developing portions of the globe.” The repeated identification of birth control with national economic planning rather than women’s individual autonomy is worth noting.

Continuing Sanger’s strategy of courting elite opinion as a more effective form of lobbying, Planned Parenthood’s medical director, Mary Calderone, convened a conference of her fellow physicians in 1955 to begin pressing for the legalization of abortion for medical purposes. By 1969, the demand for therapeutic abortions had grown to a demand for the legalization of abortion in all circumstances, which remains Planned Parenthood’s position today and, thanks in no small part to its very effective litigation efforts, is the law of the land.

As in Sanger’s time, Planned Parenthood keeps an eye on the money and has a corporate gift for insinuation: It lobbied the Nixon administration successfully for an amendment to public-health laws, as a result of which the organization today pulls in more than half a billion dollars in federal-government funds alone, largely through Medicaid. In 1989, it founded an advocacy arm, Planned Parenthood Action Fund, that today encompasses a political-action committee and super PAC that ranks No. 23 out of 206 outside-spending groups followed by OpenSecrets.org, putting a little over $12 million into almost exclusively Democratic pockets during the 2016 election cycle.

In Planned Parenthood’s hometown of New York City, a black woman is more likely to have an abortion than to give birth: 29,007 abortions to 24,108 births in 2013.

Is it working? Lothrop Stoddard, author of The Rising Tide of Color against White World Supremacy, might be gratified to note that, in Planned Parenthood’s hometown of New York City, a black woman is more likely to have an abortion than to give birth: 29,007 abortions to 24,108 births in 2013. African Americans represent about 12 percent of the population and about 36 percent of the abortions; Catholics, disproportionately Hispanic and immigrant, represent 24 percent. In total, one in five U.S. pregnancies (excluding miscarriages) ends in abortion, and most women who have abortions already have at least one child. The overwhelming majority of them (75 percent, as Guttmacher reckons it) are poor. The public record includes no data about the “feebleminded” or otherwise “unfit,” but the racial and income figures suggest that Planned Parenthood is today very much functioning as its Progressive-era founders intended.

If Planned Parenthood’s operating model remains familiar after 100 years, so does the rhetoric of the abortion movement. Sanger herself relayed the experience of the Scottish ethnologist John Ferguson McLennan: “When a traveller reproached the women of one of the South American Indian tribes for the practice of infanticide, McLennan says he was met by the retort, ‘Men have no business to meddle with women’s affairs.’”

— Kevin D. Williamson is National Review’s roving correspondent. This article first appeared in the June 12, 2017, print issue of National Review.

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A Plan for Peace
by Margaret Sanger
Birth Control Review
April 1932, pp. 107-108

Fact Check: Was Planned Parenthood Started To 'Control' The Black Population?
by Amita Kelly
npr.org
August 14, 201512:59 PM ET...

On Fox News Wednesday, Carson was asked about Democrats' criticism that Republicans who want to defund Planned Parenthood are waging a "war on women." He responded:

"Maybe I am not objective when it comes to Planned Parenthood, but, you know, I know who Margaret Sanger is, and I know that she believed in eugenics, and that she was not particularly enamored with black people.

"And one of the reasons you find most of their clinics in black neighborhoods is so that you can find a way to control that population. I think people should go back and read about Margaret Sanger who founded this place — a woman Hillary Clinton by the way says that she admires. Look and see what many people in Nazi Germany thought about her."

...

In response, Planned Parenthood said Carson was not only "wrong on the facts, he's flat-out insulting."...

Did Margaret Sanger believe in eugenics?

Yes, but not in the way Carson implied.

Eugenics was a discipline, championed by prominent scientists but now widely debunked, that promoted "good" breeding and aimed to prevent "poor" breeding. The idea was that the human race could be bettered through encouraging people with traits like intelligence, hard work, cleanliness (thought to be genetic) to reproduce. Eugenics was taken to its horrifying extreme during the Holocaust, through forced sterilizations and breeding experiments.

In the United States, eugenics intersected with the birth control movement in the 1920s, and Sanger reportedly spoke at eugenics conferences. She also talked about birth control being used to facilitate "the process of weeding out the unfit [and] of preventing the birth of defectives."

"I was merely thinking of the poor mothers of congested districts of the East Side who had so poignantly begged me for relief, in order that the children they had already brought into the world might have a chance to grow into strong and stalwart Americans . . . Birth Control is not contraception indiscriminately and thoughtlessly practiced. It means the release and cultivation of the better racial elements in our society, and the gradual suppression, elimination and eventual extirpation of defective stocks — those human weeds which threaten the blooming of the finest flowers of American civilization."

-- Apostle of Birth Control Sees Cause Gaining Here; Hearing in Albany on Bill to Legalize Practice a Milestone in Long Fight of Margaret Sanger -- Even China Awakening to Need of Selective Methods, She Says, by New York Times, April, 1923

Historians seem to disagree on just how involved in the eugenics movement she was. Some contend her involvement was for political reasons — to win support for birth control.

In reading her papers, it is clear Sanger had bought into the movement. She once wrote that "consequences of breeding from stock lacking human vitality always will give us social problems and perpetuate institutions of charity and crime."

"That Sanger was enamored and supported some eugenicists' ideas is certainly true," said Susan Reverby, a health care historian and professor at Wellesley College. But, Reverby added, Sanger's main argument was not eugenics — it was that "Sanger thought people should have the children they wanted."

It was a radical idea for the time.

Sanger wrote about this mission herself in 1921: "The almost universal demand for practical education in Birth Control is one of the most hopeful signs that the masses themselves today possess the divine spark of regeneration."...

Her attitude toward African-Americans can certainly be viewed as paternalistic, but there is no evidence she subscribed to the more racist ideas of the time or that she coerced black women into using birth control.

While Sanger can be considered racist and classist to the extent that many people were during the twentieth century, it is erroneous to overextend that allegation and claim the activist was a proponent of race control.

-- The “Feeble-Minded” and the “Fit”: What Sanger Meant When She Talked about Dysgenics, by Taylor Sullivan, sangerpapers.com

In fact, for her time, as the Washington Post noted, "she would likely be considered to have advanced views on race relations."....

First, put into action President Wilson's fourteen points, upon which terms Germany and Austria surrendered to the Allies in 1918. Second, have Congress set up a special department for the study of population problems and appoint a Parliament of Population, the directors representing the various branches of science: this body to direct and control the population through birth rates and immigration, and to direct its distribution over the country according to national needs consistent with taste, fitness and interest of individuals.

The main objects of the Population Congress would be:

a) to raise the level and increase the general intelligence of population.

b) to increase the population slowly by keeping the birth rate at its present level of fifteen per thousand, decreasing the death rate below its present mark of 11 per thousand.

c) to keep the doors of immigration closed to the entrance of certain aliens whose condition is known to be detrimental to the stamina of the race, such as feebleminded, idiots, morons, insane, syphilitic, epileptic, criminal, professional prostitutes, and others in this class barred by the immigration laws of 1924.

d) to apply a stern and rigid policy of sterilization and segregation to that grade of population whose progeny is tainted, or whose inheritance is such that objectionable traits may be transmitted to offspring.

e) to insure the country against future burdens of maintenance for numerous offspring as may be born of feebleminded parents, by pensioning all persons with transmissible disease who voluntarily consent to sterilization.

f) to give certain dysgenic groups in our population their choice of segregation or sterilization.

g) to apportion farm lands and homesteads for these segregated persons where they would be taught to work under competent instructors for the period of their entire lives.

The first step would thus be to control the intake and output of morons, mental defectives, epileptics.

The second step would be to take an inventory of the secondary group such as illiterates, paupers, unemployables, criminals, prostitutes, dope-fiends; classify them in special departments under government medical protection, and segregate them on farms and open spaces as long as necessary for the strengthening and development of moral conduct.

Having corralled this enormous part of our population and placed it on a basis of health instead of punishment, it is safe to say that fifteen or twenty millions of our population would then be organized into soldiers of defense--- defending the unborn against their own disabilities.

The third step would be to give special attention to the mothers' health, to see that women who are suffering from tuberculosis, heart or kidney disease, toxic goitre, gonorrhea, or any disease where the condition of pregnancy disturbs their health are placed under public health nurses to instruct them in practical, scientific methods of contraception in order to safeguard their lives---thus reducing maternal mortality.

The above steps may seem to place emphasis on a health program instead of on tariffs, moratoriums and debts, but I believe that national health is the first essential factor in any program for universal peace.

With the future citizen safeguarded from hereditary taints, with five million mental and moral degenerates segregated, with ten million women and ten million children receiving adequate care, we could then turn our attention to the basic needs for international peace.

There would then be a definite effort to make population increase slowly and at a specified rate, in order to accommodate and adjust increasing numbers to the best social and economic system.

In the meantime we should organize and join an International League of Low Birth Rate Nations to secure and maintain World Peace.

[admin]

The Birth Control Review
by onlinebooks.library.upenn.edu
Accessed: 4/4/20

The Birth Control Review was a birth control advocacy publication published in the US in the early 20th century by the American Birth Control League (and late in its run, by its successor, the Birth Control Federation of America).

Publication History

The Birth Control Review was begun in 1917 by Margaret Sanger, who edited the Review until 1929. A new series began in 1933. No issue or contribution copyright renewals were found for this serial. It ceased publication in 1940.

Persistent Archives of Complete Issues

1917-1925: HathiTrust has volumes 1-9.
1917-1940: Life Dynamics has most issues of this serial linked from its "Archives of the American Holocaust" page.

[admin]

Eugenic Sterilization: An Urgent Need
by Professor Dr. Ernst Rudin
Birth Control Review [Margaret Sanger / Planned Parenthood]
April, 1933

Ernst Rüdin: Hitler's Racial Hygiene Mastermind.
by Jay Joseph and Norbert A. Wetzel
Journal of the History of Biology
Vol. 46, No. 1 (Spring 2013), pp. 1-30.

Ernst Rüdin (1874-1952) was the founder of psychiatric genetics and was also a founder of the German racial hygiene movement. Throughout his long career he played a major role in promoting eugenic ideas and policies in Germany, including helping formulate the 1933 Nazi eugenic sterilization law and other governmental policies directed against the alleged carriers of genetic defects. In the 1940s Rüdin supported the killing of children and mental patients under a Nazi program euphemistically called "Euthanasia." The authors document these crimes and discuss their implications, and also present translations of two publications Rüdin co-authored in 1938 showing his strong support for Hitler and his policies. The authors also document what they see as revisionist historical accounts by leading psychiatric genetic authors. They outline three categories of contemporary psychiatric genetic accounts of Rüdin and his work: (A) those who write about German psychiatric genetics in the Nazi period, but either fail to mention Rüdin at all, or cast him in a favorable light; (B) those who acknowledge that Rüdin helped promote eugenic sterilization and/or may have worked with the Nazis, but generally paint a positive picture of Rüdin's research and fail to mention his participation in the "euthanasia" killing program; and (C) those who have written that Rüdin committed and supported unspeakable atrocities. The authors conclude by calling on the leaders of psychiatric genetics to produce a detailed and complete account of their field's history, including all of the documented crimes committed by Rüdin and his associates.

Excerpt from a pamphlet "Psychiatric Indication for Sterilization," Issued by the Committee for Legalizing Sterilization, Eugenics Society, London, originally published in Das Kommende Geschlecht, Germany, Band V, Heft 3

THE following essay is concerned only with sterilization as a voluntary practice, that is, when undertaken with the consent of the patient himself or his statutory guardians. The reasons warranting the operation (in medical parlance, indications) may be classified as therapeutic indications, which are concerned with the health of the individual, and eugenic indications, aimed at the protection of the race.

Probably our greatest eugenic anxiety is caused by the vast army of psychopaths, i.e., of patients so maladjusted by reason of their psychological and temperamental make-up that, though they cannot be called psychotic, nevertheless cause unhappiness both to themselves and their relations. Occupational inefficiency, distaste for life, suicidal tendencies, cruelty, sex perversions and grave criminal tendencies all come within this category and contribute in incalculable measure to human suffering. The inextricable tangle of environmental and hereditary factors exhibited by these types has so far prevented any attempt to work out a genetic prognosis for this group. I refrain from giving you any of the numerous family histories which we have collected in this series, as we still lack statistically valid prognosis.

As concerns mental defectives, there is, of course, no necessity for accessory methods of preventing procreation in those low grades which require permanent segregation. The public however is insufficiently aware of the results of allowing feeble-minded males the liberty to procreate. The danger to the community of the unsegregated feeble-minded woman is more evident. Most dangerous are the middle and high grades living at large who, despite the fact that their defect is not easily recognizable, should nevertheless be prevented from procreation. Here, of course, action should only be taken after careful personal examination and a survey of the family pedigree.

Here, we may interpolate some more general considerations. Quite apart from exigencies of heredity, sterilization might well be advocated in the case of psychotics, psychopaths and the feeble-minded, for, at best these persons make most unsuitable parents. Their families may too easily become foci of suffering in the present generation and, by reason of the traditionally low standards in which their children are brought up, in generations to come. I will not, however, enlarge on this point, on which I am not prepared to express an opinion. I need only mention that in regard to their genetics and fertility, these groups require further investigation before we can arrive at a more clear-cut and definite policy in regard to sterilization.

So far, we have been considering the voluntary sterilization of the individual patient, whether mentally diseased or mentally subnormal.

Consideration should now be given to the case of the individual who, though not himself a sufferer, may be a carrier or potential transmitter of mental disease. The figures given above show that the relatives of mental patients, while not themselves insane in the strict sense of the word, are frequently psychologically ill-endowed. If they have children there is an obvious likelihood of their children being abnormal. Every day we recognize more clearly that many of these cases, though superficially regarded as normal, show some minor deviation from normality by which the type may be recognized. The chief task of scientific geneticists cooperating with clinicians in the near future is the discovery of these symptomatic deviations with the object of facilitating the detection of the carrier.

This still leaves a considerable group of persons who show no abnormality suggestive of their being carriers, but who, as relatives of insane patients, are, nevertheless, suspect in regard to the normality of their offspring. At the moment no clear-cut solution is available. In these cases, each would be judged on the prognosis of transmission for the particular disease and grade of relationship. We can only look to greatly extended research in the future, in the hope of eventually ascertaining their genetic constitution.

My experience has led me to the conclusion that systematic and careful propaganda should be undertaken where sterilization is advisable. Such propaganda should, of course, be gradual and should be directed in the first instance at the medical directors in institutions and schools, medical officers of health, and finally at private practitioners. The instruction of the individual patient is even more important than propaganda amongst the medical profession, and I cannot lay too much stress on the necessity for very close personal contact between the medical adviser and the patient and his nearest relatives. It is necessary to go into the details of each individual case with friendliness and patience. The medical man should explain the situation to those concerned and emphasize to them the harmlessness of sterilization as well as its great advantages for the race -- assurances which may be given with perfect sincerity. He can further stress the fact that this operation would lessen the burden on the individual. I conceive that the converse propaganda will be much more difficult, namely, the attempt to persuade the well-endowed to have a sufficiently large family. The standard of living which prevails in civilized communities today makes it a very considerable sacrifice for responsible people to undertake the upbringing of children.

There would appear to be no good reason to prohibit marriage to the sterilized party (provided a partner fully acquainted with the situation be found) as it is only procreation which should be avoided. Eugenists would deplore that a normal spouse should be prevented from procreation by mating with a sterilized patient, but it is a contingency unlikely to arise, as those familiar with such cases are well aware. In our experience, normal and subnormal rarely mate. This is, however, a point on which further research is being undertaken.

Individual objections to sterilization need really not be feared where careful explanations and advice are given. Consent would, however, be obtained more generally if the operation were offered free of cost to those in poor circumstances. In fact, it would be a very wise provision on the part of public authorities to offer facilities for this operation as freely as facilities for therapeutic operations are now offered. The policy would effect considerable economies in expenditure on health services. Certain legal safeguards will, of course, be necessary. Thus, it should be made obligatory to obtain the consent of the partner to a marriage so as to prevent disappointment in cases where children are desired.

Something should be said about the possibility of abuses. From this point of view, birth control is far more to be feared than sterilization. Indeed, I regard this fear of abuses as a bugbear. Where sterilization would become operative amongst the most degenerate group in the community, it could, in some degree, compensate for the widespread use of birth control in the well-endowed and middleclass groups.

There is absolutely no question of using compulsion. Whether in the far future something of the sort might be required cannot be predicted now. I do not foresee any such necessity, despite the suggestion of some people that anti-social qualities such as the carelessness or ill-will of some part of the community might call for such measures.

On biological grounds it is quite clear that many more defects and miseries are due to heredity than those of which the transmission has so far been clearly ascertained, and we should be well advised not to limit ourselves to advocating sterilization in the worst cases, which, after all, show a certain tendency to eliminate themselves. There is no need to sterilize cases which are already psychological wrecks and for most part destitute of any initiative. The public watch unmoved the falling birthrate amongst the well-endowed, which amounts to a veritable hecatomb and yet raises an outcry at the attempt to eliminate any single clear-cut cause of hereditary misery. We have ample evidence of the suffering entailed both for themselves and the community by the "social problem" group, the desirability of reducing which, to an enlightened public opinion, should amply justify sterilization.

And here I may refer to the frequent correlation of physical and psychological defects, both of which are transmissible, in the same stock. Sometimes neither of these alone would be regarded as a justification for preventing procreation, but the two combined clearly call for action. On the other hand, cases arise where the hereditary taint coexists with some outstanding valuable character, and the two tendencies must be carefully balanced one against the other. In short, genetic prognosis will become more and more urgently necessary, and I repeat that birth control is wholly inadequate as a means of preventing procreation in the group where prevention is most necessary.

In my view we should act without delay. Not only is it our task to prevent the multiplication of bad stocks, it is also to preserve the well-endowed stocks and to increase the birth-rate of the sound average population. The oft-encountered objection that genius or talent is frequently associated with insanity has no solid foundation. It is a purely fortuitous correlation. We are now investigating the question whether these cases do or do not lie within the general expectation of insanity. But even supposing that the above proposition could stand, we have to consider how the highest type of intellect can be preserved, without at the same time paying for it by mental abnormality.

Careful and authoritative pronouncements in regard to the laws of transmission are imperatively required. We need a wider appreciation of the eugenic indications for sterilization. Vague general statements as to suitable cases I hold to be of very little use. It is to individual, kindly medical teaching and advice that we must look for results.

Finally, research in hereditary prognosis must be actively stimulated. Appropriate legislative measures will readily follow the acquisition of definite and reliable knowledge.

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Part 1 of 2

Ernst Rüdin: Hitler’s Racial Hygiene Mastermind
by Jay Joseph and Norbert A.Wetzel
Article in Journal of the History of Biology
November 2012

JAY JOSEPH
P.O. Box 5653, Berkeley, CA 94705-5653, USA
E-mail: jayjoseph22@gmail.com

NORBERT A. WETZEL
The Center for Family, Community, and Social Justice, Inc.,
166 Bunn Dr., Suite #105, Princeton, NJ 08540, USA
E-mail: norbertwetzel@cfcsj.net

-- Eugenic Sterilization: An Urgent Need, by Professor Dr. Ernst Rudin

Abstract. Ernst Rudin (1874–1952) was the founder of psychiatric genetics and was also a founder of the German racial hygiene movement. Throughout his long career he played a major role in promoting eugenic ideas and policies in Germany, including helping formulate the 1933 Nazi eugenic sterilization law and other governmental policies directed against the alleged carriers of genetic defects. In the 1940s Rudin supported the killing of children and mental patients under a Nazi program euphemistically called ‘‘Euthanasia.’’ The authors document these crimes and discuss their implications, and also present translations of two publications Rudin co-authored in 1938 showing his strong support for Hitler and his policies. The authors also document what they see as revisionist historical accounts by leading psychiatric genetic authors. They outline three categories of contemporary psychiatric genetic accounts of Rudin and his work: (A) those who write about German psychiatric genetics in the Nazi period, but either fail to mention Rudin at all, or cast him in a favorable light; (B) those who acknowledge that Rudin helped promote eugenic sterilization and/or may have worked with the Nazis, but generally paint a positive picture of Rudin’s research and fail to mention his participation in the ‘‘euthanasia’’ killing program; and (C) those who have written that Rudin committed and supported unspeakable atrocities. The authors conclude by calling on the leaders of psychiatric genetics to produce a detailed and complete account of their field’s history, including all of the documented crimes committed by Rudin and his associates.

The purpose of this article is to examine the career of the Swiss-German racial hygienist and psychiatric genetics founder Ernst Rudin (1874–1952), and to document the crimes he both supported and committed in Germany during the Nazi period (1933–1945). We then assess the manner in which contemporary psychiatric genetic researchers have written about -– or have failed to write about –- the crimes committed by Rudin and his associates. Following this discussion, we present translations of two documents co-authored by Rudin and racial hygienics founder Alfred Ploetz (1860–1940) in a 1938 edition of Archiv fur Rassen-und Gesellschaftsbiologie (Archive for Racial and Social Biology; Ploetz and Rudin, 1938a, b). To the best of our knowledge these documents have not been translated in any previous English language publication.

Psychiatric Genetics and Racial Hygiene

Ploetz and Rudin were among the founders of the German Society for Racial Hygiene (Gesellschaft fur Rassenhygiene) in 1905. The aims of the German racial hygiene movement were similar to the eugenics movements in other countries, including the United States, although the term ‘‘race’’ (Rasse) implied a stronger racial or volkisch aspect of eugenics. German racial hygienists and other eugenicists believed that humans can be ‘‘improved’’ by selective breeding to eradicate ‘‘undesirable’’ traits in the population. They argued that psychiatric disorders, and traits such as criminality, alcoholism, and hereditary ‘‘feeble-mindedness’’ (angeborener Schwachsinn) are caused mainly by hereditary factors, and can be bred out of the population for the benefit of future generations. The Archiv first appeared in Germany in 1904 and became the official journal of the Society for Racial Hygiene. After the Nazi seizure of power in the first part of 1933, it became an official organ of the Nazi’s Reich Committee for Public Health (Weindling, 1989, p. 500), with Rudin continuing as the co-Editor.

Rudin developed the psychiatric genetics field in the early twentieth century. During that period he was working with the founder of modern psychiatry Emil Kraepelin, first in Heidelberg, and then following Kraepelin to Munich in 1907 (Weber, 1996). Rudin and his racial hygienicist colleagues were tireless advocates of programs aimed against the carriers of a presumed ‘‘hereditary taint’’ (erbliche Belastung) well before the Nazi seizure of power in 1933. Lacking any family or twin studies, Rudin called for the eugenic sterilization of chronic alcoholics as early as 1903, which ‘‘marked the beginning of a life-long crusade for sterilization of the degenerate’’ (Weindling, 1989, p. 186).

The Nazi takeover provided new support for Rudin’s ‘‘crusade,’’ and he played a major role in creating and implementing the 1933 Nazi ‘‘Law for the Prevention of Genetically Diseased Offspring’’ (Gesetz zur Verhutung erbkranken Nachwuchses). This law provided for the compulsory eugenic surgical sterilization of people diagnosed with ‘‘genetic’’ conditions such as feeble-mindedness, schizophrenia, manic-depressive insanity, genetic epilepsy, Huntington’s chorea, genetic blindness or deafness, or severe alcoholism. Rudin was a co-author of the official commentary summarizing the alleged scientific justification for the law (Gutt et al., 1934).1

The law created a massive program of compulsory eugenic sterilization and led to the establishment of roughly 1,700 hereditary health courts (Erbgesundheitsgerichte) throughout Germany (Proctor, 1988). Approximately 400,000 Germans were forcibly sterilized under the law between 1934 and 1939, primarily on the basis of being labeled ‘‘feeble-minded’’ or ‘‘schizophrenic.’’ The sterilization mortality rate was around 0.5%, meaning that perhaps 2,000 people died from the operation (Proctor, 1988).

Rudin and his close psychiatric geneticist associates at the Genealogic-Demographic Department of the German Research Institute for Psychiatry in Munich, such as Hans Luxenburger and Bruno Schulz, played a major role in establishing, popularizing, and performing research in support of the sterilization law (Joseph, 2004, 2006; Lewis, 1934; Luxenburger, 1934; Rudin, 1934; Schulz, 1934, 1939). In 1934, the Kaiser-Wilhelm-Institute produced a list of 15 ‘‘eminent eugenicists in Germany,’’ with Rudin and Luxenburger appearing on this list (Thomalia, 1934, pp. 141–142). Rudin received numerous awards for his work in the Nazi era, including the prestigious Goethe Medal of Arts and Sciences in 1939 from the Reich Ministry of the Interior. In 1944, Rudin received the Adlerschild des Deutschen Reiches medal (Eagle Shield of the German Reich) bearing the Nazi eagle from Hitler, and was praised as being a ‘‘pathfinder in the field of hereditary hygiene’’ (Weinreich, 1946, p. 33).

Like Rudin, Luxenburger was a strong supporter of eugenic measures well before the Nazi seizure of power in 1933 (see Burleigh, 1994; Joseph, 2004, pp. 34–39; Luxenburger, 1931a, b). As Weiss observed in her detailed examination of Rudin’s Institute, ‘‘all of its members were strong supporters of eugenics during the Weimar years’’ (1919–1933; Weiss, 2010, p. 133). In 1931, Luxenburger wrote that sterilization would ‘‘considerably contain’’ but not ‘‘fully prevent the transmission of recessive hereditary properties.’’ Nevertheless, he supported sterilization because ‘‘it is impossible to see why one should sit back and do nothing only because a radical eradication of degenerate hereditary properties is still impossible today’’ (quoted in Burleigh, 1994, p. 41). After the Nazi takeover, Luxenburger’s definition of ‘‘feeble-minded’’ children deserving to fall under the sterilizer’s knife included those having great difficulty in elementary school and those ‘‘who fail in life’’ (Weiss, 2010, p. 144). When asked whether the sterilization law would reduce the number of people available to perform important menial tasks, Luxenburger replied, ‘‘even after sterilization there will be enough hereditary feeble-minded individuals to serve as coolies’’ (quoted in Weiss, 2010, p. 144).

After the Nazi seizure of power, researchers and students from other European countries came to Munich to study under Rudin and his associates at the Genealogical-Demographic Department. According to David Rosenthal, a leading American supporter of psychiatric genetics and an admirer of Rudin’s scientific work, ‘‘From this institute emerged all of the pioneering psychiatric geneticists’’ (Rosenthal, 1971, p. 7).

Rudin and ‘‘Euthanasia’’

In the late 1930s the Nazi regime moved beyond compulsory eugenic sterilization and instituted a secret plan to kill mental patients and other ‘‘defectives,’’ ‘‘useless eaters,’’ and ‘‘incurables.’’ This program, code named ‘‘T4’’ and euphemistically referred to by the authorities as ‘‘euthanasia,’’ led to the murder of 70,000 people by gas, lethal injection, starvation, and other methods in the first phase between 1939 and 1941 under the direction of the government and leading doctors and psychiatrists (Lifton, 1986; Proctor, 1988). Many more were killed between 1939 and 1945 in further actions both in Germany and the occupied territories. Some have estimated that 200,000 people were killed in the program (Weiss, 2010), while other estimates run as high as 300,000 (Peters, 2001). Proposals to institute a eugenic killing program in the United States were openly debated in a 1942 edition of the official journal of the American Psychiatric Association, The American Journal of Psychiatry (Joseph, 2005; Kennedy, 1942).

Although there is no evidence that Rudin played a major role in initiating the ‘‘euthanasia’’ program, it is beyond question that he helped implement and justify this program of killing (Roelcke, 2000, 2012;Weiss, 2010). According to Rudin’s biographer Matthias Weber, in internal memorandums Rudin discussed ‘‘euthanasia’’ as a type of ‘‘therapeutic reform’’ (Weber, 1996, p. 329). The German historian of medicine Volker Roelcke has played an important role in documenting Rudin’s involvement in the euthanasia program, and has criticized what he saw as Weber’s (1993) incomplete reporting (including poorly documented claims) of Rudin’s role in the killing program (Roelcke, 2006, 2012). In 1942 Rudin wrote about the eugenic importance of ‘‘distinguishing which children could, already as children, be clearly categorized as so valueless and worthy of elimination that…they could be recommended for euthanasia in their own interest and that of the German people’’ (quoted in Weiss, 2010, p. 179).

Roelcke has documented Rudin’s support for the killing of children at the Psychiatric Department of the University of Heidelberg in 1943–1945 (Roelcke, 2000, 2006, 2012; Roelcke et al., 1998). He has shown that Carl Schneider and Rudin’s associate Julius Deussen ‘‘played a leading role in the research on children in the context of the euthanasia program’’ (Roelcke, 2006, p. 86). This research included the killing of children in order to ‘‘systematically correlate clinical with post-mortem and histopathological data.’’ Roelcke has documented that Rudin ‘‘supported the research efforts of Schneider and Deussen in various ways, among other things with funds from the budget of his own institute in Munich’’ (Roelcke, 2006, p.87). The research carried out by Deussen and Schneider attempted to find clinical, genealogical, and/or laboratory criteria to differentiate between hereditary and acquired conditions. At least 21 of the 52 children studied under the program initiated and supported by Rudin were killed so that their brains could be examined (Roelcke, 2000, 2012).

The brains of other murdered ‘‘euthanasia’’ victims were sent to Rudin’s Munich institute for evaluation and research (Weiss, 2010, p. 183). According to Weber, ‘‘Rudin considered the broadening of the criteria for killing handicapped newborns to be a scientific issue of importance to the war effort’’ (Weber, 2000, p. 255). In 1944, Rudin considered publishing an article in the Archiv legitimizing euthanasia based on ‘‘thoroughly investigated children’’ (quoted in Weiss, 2010, p. 179). Clearly, at this point Rudin still believed that Germany would win the war and that open support for euthanasia in scientific journals would become acceptable after the German victory.

Rudin and his collaborators drafted a memorandum on the Nazi T4 ‘‘euthanasia’’ killing program, discussing ways that doctors and others could justify the killing. According to the memorandum:

Even the euthanasia measures will meet with general understanding and approval, as it becomes established and more generally known that, in each and every case of mental disease, all possible measures were taken either to cure the patients or to improve their state sufficiently to enable them to return to work which is economically worthwhile, either in their original professions or in some other occupation. (quoted in Muller-Hill, 1998, p. 46)

And in a 1942 letter to the Reich Research Council discussing psychiatric genetics and the conditions of war, Rudin wrote,

We have no interest in preserving the lives of incurable and ruinous victims of heredity, nor do we have any interest in the propagation of individuals who are carriers of the genetic dispositions necessary for the development of severe hereditary diseases. We do however have an interest in the case of the latter individuals to save what can be saved, at least on a case-by-case basis, by means of timely interventions in pathogenesis and during the course of the disease, in order to at least preserve their utility to society. (quoted in Ritter and Roelcke, 2005, p. 268)

Similar to the selection process at the Nazi’s Auschwitz concentration camp, Rudin condemned to death the ‘‘incurable and ruinous victims of heredity’’ unless they were able-bodied enough to contribute to the war effort or to work in slave labor camps. In the words of a pair of contemporary schizophrenia researchers, ‘‘The sterilization and murder of hundreds of thousands of patients with schizophrenia and other psychiatric disorders in Nazi Germany between 1934 and 1945 was the greatest criminal act in the history of psychiatry’’ (Torrey and Yolken, 2010, p. 31).

Indeed, as the contemporary German psychiatric genetic researcher Peter Propping concluded, the leaders of Rudin’s Munich school were responsible for moving along the ‘‘slippery slope’’ from sterilization to killing2:

When the National Socialists came to power in Germany in 1933, the protagonists of the Munich school helped guide psychiatric genetics along the slippery slope from the sterilization of psychiatric patients to their deaths in an organized euthanasia program. Ernst Rudin was a prominent protagonist of the German racial hygiene movement, his research program as well as his political activities being guided by the idea of a ‘‘healthy race.’’ (Propping, 2005, p. 3)

According to Roelcke,

The aim of re-structuring society according to the laws of biology was the guiding principle motivating all of Rudin’s research and political activities. He and most of his staff were in one way or another involved in Nazi mental health policy, including active support of the systematic patient killings (‘‘euthanasia’’), and in research aimed at finding scientifically valid criteria for distinguishing between those worthy for procreation, or indeed worthy to live, and those supposedly unworthy. (Roelcke, 2004, p. 477)

Historians have pointed out that in addition to the eugenic and ‘‘racial purification’’ aspects of the euthanasia program, other motives included economic factors and the need to clear out hospitals and asylums in the interest of the war effort (Germany invaded Poland on September 1, 1939). However, although the euthanasia program was carried out under the conditions of war, from another perspective one could argue that, much like the Holocaust itself, it was carried out under the cover of war.

Rudin’s anti-Semitism was also in line with the Nazi leaders he so willingly collaborated with and even inspired. As seen in two 1938 articles he co-authored with Ploetz (which we have translated below) and elsewhere, Rudin supported every policy and crime directed against the Jewish people, which is confirmed in a 1942 edition of the Archiv. Referring to the ‘‘fight against parasitic alien races such as the Jews and Gypsies’’ well after Kristallnacht and at a time when the Holocaust was well underway, Rudin wrote,

The results of our science had earlier attracted much attention (both support and opposition) in national and international circles. Nevertheless, it will always remain the undying, historic achievement of Adolf Hitler and his followers that they dared to take the first trail-blazing and decisive steps toward such brilliant race-hygienic achievement in and for the German people. In so doing, they went beyond the boundaries of purely scientific knowledge. He and his followers were concerned with putting into practice the theories and advances of Nordic race-conceptions… the fight against parasitic alien races such as the Jews and Gypsies… and preventing the breeding of those with hereditary diseases and those of inferior stock. (quoted in Muller-Hill, 1998, p. 67)

In the same article, Rudin wrote favorably about Nazi racial laws, which led to a ‘‘by now progressed elimination of Jewish influence and especially to the prevention of further intrusions of Jewish blood into the German gene pool.’’ Like Hitler, he saw the war as being caused by ‘‘Jewish-plutocratic and Bolshevik directed powers’’ (Rudin, 1942, pp. 321–322; see also Joseph, 2004).

Questionable Premises: Then and Now

German psychiatric geneticists sought to provide alleged scientific evidence in support of social and political policies aimed at curbing the reproduction of people they targeted as harboring ‘‘hereditary taint,’’ which they believed posed a grave danger to society and could lead to societal and racial degeneration (Peters, 2001; Roelcke, 2006; Schulze et al., 2004). However, although contemporary psychiatric genetic researchers usually reject eugenic ideas and programs (while promoting genetic counseling), they may be just as mistaken as Rudin and his colleagues in their belief that hereditary factors play an important etiological role in the major psychiatric disorders (Joseph, 2004, 2006, 2012).

The reason is that contemporary researchers -– in the context of the forty-year failure to discover the genes that they believe cause the major psychiatric disorders (Collins et al., 2012; Gershon et al., 2011; Joseph, 2011, 2012; Joseph and Ratner, in press; Plomin, 2012) -– rely on the same two environmentally confounded research methods used by Rudin and his colleagues: psychiatric family studies and twin studies. Then as now, critics have argued that both family studies and twin studies are unable to disentangle the potential influences of genes and environment, and therefore prove nothing about genetic influences on psychiatric disorders and psychological traits (Charney, 2008a, b, 2012, Joseph, 2004, 2006, 2010, 2012; Lewontin et al., 1984). In addition, critics have argued that psychiatric adoption studies, which have been performed since the 1960s, contain their own set of invalidating methodological problems and environmental confounds (Boyle, 2002; Cassou et al., 1980; Joseph, 2004, 2006, 2010; Pam, 1995; Lewontin et al., 1984; Lidz, 1976; Lidz and Blatt, 1983; Lidz et al., 1981).

The main product of Munich school research was the ‘‘empirical genetic prognosis’’ (empirische Erbprognose), which involved calculating the probability that (presumably hereditary) psychiatric disorders would eventually appear in the biological relatives and descendants of people diagnosed with these disorders. These calculations, which were based mainly on family studies, produced age-corrected ‘‘morbidity risk’’ (MR) percentage figures for various groups of relatives biologically related to the diagnosed ‘‘Proband.’’ Rudin had developed this method for his schizophrenia family study, published in 1916 (Rudin, 1916). Much of the work of Rudin, Luxenburger, Schulz and their colleagues in the Nazi era involved calculating such probabilities in the service of the sterilization law and other racial hygienic measures. For example, the researchers found that the age-corrected schizophrenia morbidity risks among the parents and offspring of schizophrenia patients were higher than the rate expected in the general population, and concluded that these elevated rates were caused by genetic factors. In these studies the researchers did not diagnose relatives blindly, did not use control groups, and used vague and differing definitions of schizophrenia and other disorders (Gottesman et al., 1987).

However, like their fellow eugenicists in the United States who based many of their theories and policy recommendations on allegedly ‘‘tainted family lines’’ such as the ‘‘Jukes’’ and the ‘‘Kallikaks,’’ on a purely scientific level Rudin and his Munich colleagues made the crucial error of assuming that hereditary factors explain the finding that psychiatric disorders tend to ‘‘run in the family.’’ As most contemporary psychiatric genetic and behavioral genetic researchers now understand, traits and disorders can aggregate in families for environmental (nongenetic) reasons because family members share a common environment as well as common genes. As one example, a leading group of psychiatric genetic researchers recognized in 1994 that the familial resemblance or aggregation of a trait or disorder ‘‘can occur because of shared genes, shared environment or a combination of the two’’ (McGuffin et al., 1994, p. 30; other researchers recognizing that family studies cannot disentangle potential genetic and environmental influences include Barondes, 1998; Bouchard and McGue, 2003; Faraone et al., 1999; Kendler, 1988; Kety et al., 1968; Plomin et al., 2008; Rosenthal, 1970).

Empirical predictions based on family studies, therefore, do not prove anything about genetics, and the belated recognition of this fact by the field of psychiatric genetics suggests that the most generous conclusion one can reach about Munich school research is that it was based on questionable science, if it was science at all, and was performed and promoted in the service of eugenics and right-wing political programs, the desire of institute leaders to maintain funding and the support of the Nazi regime, and their pre-existing beliefs about the importance of heredity.

Rudin’s daughter Edith Zerbin-Rudin became a psychiatric genetic researcher in Germany in the decades following World War II, first continuing her father’s work on a greatly reduced scale alongside Schulz at the renamed Max Planck Institute for Psychiatry in Munich, and then heading the department after Schulz’s death in 1958 (Zerbin-Rudin and Kendler, 1996). In a 1972 article on the genetics of schizophrenia, Zerbin-Rudin observed that although up to the end of the war most researchers accepted empirical genetic prognoses based on family study data as ‘‘unequivocal proof’’ that schizophrenia and other psychiatric disorders and traits were caused by heredity, ‘‘the interpretation has undergone change’’:

Until about 30 years ago [roughly the mid-1940s], the clear increase in morbidity risk with the proximity of blood kinship to a schizophrenic was considered unequivocal proof of a hereditary factor. Later, however, it was reasoned that family members become ill more frequently only because their environment is more alike than that of nonconsanguineous persons. (Zerbin-Rudin, 1972, p. 47)

Although Zerbin-Rudin consistently defended her father’s work and reputation (see Zerbin-Rudin and Kendler, 1996; Muller-Hill, 1998, pp. 130–133), and although she believed that the schizophrenia adoption studies published in the 1960s suggested that the familial aggregation of schizophrenia is ‘‘at least partly attributable to genetic factors’’ (p. 47), her assessment confirms that the conclusions of Rudin and his Munich colleagues were wrong insofar as they interpreted the results of family studies as constituting proof that hereditary factors cause (or are the main cause of) psychiatric disorders, ‘‘feeble-mindedness,’’ and so on. The ‘‘unequivocal proof’’ they produced, which contributed to the sterilization and killing of (estimating conservatively) hundreds of thousands of people, was in fact no proof at all. Indeed, although the great majority of people labeled ‘‘schizophrenic’’ in Nazi Germany were either sterilized or killed, postwar studies show a high incidence rate of new schizophrenia cases in Germany (Torrey and Yolken, 2010).

Some might object that our brief assessment of Rudin’s scientific work rests on the flawed method of reading research results from later decades back into the past. The main point, however, is that we condemn Rudin and his associates not for the conclusions they reached on the basis of their results, but rather for what they did to their fellow human beings on the basis of their conclusions. We do criticize the science, but the present analysis would not have been necessary had Rudin and his colleagues done nothing more than publish scientific articles concluding that genes play a major role. Rudin was an internationally known scientist who used his authority to support severely repressive political programs masquerading as ‘‘science,’’ and was a doctor who personally played a role in killing adults and children (‘‘patients’’).

Contemporary Revisionist Histories of Rudin and German Psychiatric Genetics

Teo and Ball (2009) discussed the ‘‘revisionist’’ historical accounts written by some twin researchers, who usually fail to mention that their discipline has its origins in eugenics and German racial hygiene (Joseph, 2004). Twin research was an area of focus at Rudin’s Munich institute as well being the specialty of Otmar von Verschuer of Germany’s Kaiser Wilhelm Institute Human Genetics Division, and later the Frankfurt Institute for Hereditary Biology and Racial Hygiene. Verschuer was one of the world’s leading twin researchers in the 1930s (Joseph, 2004; Newman et al., 1937), and also played a major role in providing scientific justification and support for the Holocaust and was an accomplice to the murder of twins at Auschwitz for ‘‘scientific’’ purposes (Ehrenreich, 2007; Lifton, 1986; Muller-Hill, 1998). After the war, Verschuer resumed his career as a university professor in Germany and continued to publish research papers and attend international conferences (von Verschuer, 1957), and was honored as a ‘‘teacher and example’’ in a special 1956 edition of Acta Geneticae Medicae et Gemellologiae (Journal of Medical Genetics and Twin Research) commemorating his 60th birthday (Gedda, 1956).

Continuing the theme of ‘‘insider’’ histories by members of a group writing about their field’s history (Danziger, 1994), Teo and Ball observed that a hallmark of revisionist history put forward by human genetic researchers reluctant to acknowledge (or possibly being unaware of) the eugenic and Nazi past of their discipline is ‘‘revisionism by omission.’’ As an example, they noted that twin researchers usually fail to discuss the history of twin research in its political and eugenic context, and omit the fact that the discoverer of the twin method, Hermann W. Siemens, was a major figure in the German racial hygiene movement by the early 1920s and later supported the Nazis and their racial policies (for example, see Siemens, 1937). In fact, some leading contemporary behavioral genetic researchers have omitted Siemens from the history of twin research (Teo and Ball, 2009, pp. 11–14; see also Joseph, 2004, pp. 17–21). In many of the psychiatric genetic ‘‘insider’’ accounts mentioned below, we find a similar ‘‘revisionism by omission’’ in discussions of the history of the psychiatric genetics field.

Three Categories of Contemporary Psychiatric Genetic Evaluations of Rudin

Contemporary psychiatric genetic evaluations of the founder of the field Ernst Rudin are varied, but usually fall into the revisionist Categories A and B discussed below. Major works covering many of the crimes of Rudin and his associates have been available in English since the 1980s (Lifton, 1986; Muller-Hill, 1998 [the first English translation appeared in 1988]; Proctor, 1988; Roelcke, 2006; Weindling, 1989), although English language documentation of Rudin’s support for the Nazi regime and the sterilization law dates back to the immediate post-war era (Weinreich, 1946) and earlier.

Category A

Category A includes leaders of the psychiatric genetics field and their supporters who have written about German psychiatric genetics in the Nazi period and who either fail to mention Rudin at all, or cast him in a favorable light. While Category A authors sometimes discuss Nazi policies and document atrocities (at times pointing to the complicity of German scientists outside of psychiatric genetics), they omit mention of Rudin’s and other German psychiatric geneticists’ role in supporting Nazism, racial hygiene, forced sterilization, the killing of mental patients (‘‘euthanasia’’), and Hitler’s persecution of Jews, Sinti and Roma (gypsies), and other targeted groups (examples of Category A authors include Faraone et al., 1999; Flint et al., 2010; Gottesman, 1991; Gottesman and Shields, 1982; Hoge and Appelbaum, 2008; McGuffin et al., 1994; Nurnberger and Berrettini, 1998; Rosenthal, 1970, 1971; Slater, 1971; Slater and Cowie, 1971; Stone, 1997; Stro¨ mgren, 1985; Torrey et al., 1994). Category A authors such as Erik Stromgren and Eliot Slater studied under Rudin in Munich in the mid-1930s and therefore had first-hand knowledge of his public and other activities. Edith Zerbin-Rudin (born in 1921) also falls into this category.

Here we provide a few examples from the Category A accounts listed above. In his award-winning book Schizophrenia Genesis, schizophrenia researcher Irving Gottesman (1991), who was mentored by Slater, wrote positively of the work of Rudin, Luxenburger, Schulz and other leaders of the ‘‘now-famous Munich school of psychiatric genetics’’ (p. 14), referring to ‘‘thoroughly the scientist’’ Rudin (p. 13), and to Schulz as a ‘‘star member of Rudin’s Munich school’’ (p. 96). In a book describing their own psychiatric twin research, biological psychiatrist E. Fuller Torrey, Gottesman and their colleagues (Torrey et al., 1994) made reference to the Nazi sterilization law, twin research under the Nazis, and the roles of Verschuer and Josef Mengele in the murder of twins at Auschwitz for alleged scientific purposes. At the same time, they discussed the work of Luxenburger in a positive way, made no mention of the role of German psychiatric genetics in supporting Nazi policies, and did not mention Rudin at all.

Faraone, Tsuang, and Tsuang, in their book Genetics of Mental Disorders (Faraone et al., 1999) failed to document the involvement of Rudin and his colleagues in German eugenic policies, and implied that their findings were merely misused by the Nazis: ‘‘Adolph Hitler and his Nazi regime began a systematic program first to sterilize and then to kill ‘genetically defective’ people…. Contemporary researchers in psychiatric genetics are especially disturbed to learn that the Nazis used [German psychiatric genetic] research to justify their eugenics policies regarding the mentally ill…’’ (pp. 223–224). They wrote only of what they saw as ‘‘Nazi abuses of psychiatric genetics’’ (p. 224).

Hoge and Appelbaum (2008), in their chapter in Psychiatric Genetics: Applications in Clinical Practice, wrote that ‘‘Eugenics reached its zenith (or nadir) in Nazi Germany’’ (p. 257). They recognized that ‘‘Psychiatrists were directly implicated in the application of eugenic programs under the Nazi regime’’ (p. 257), and discussed the eugenic sterilization law, the T4 euthanasia program, and that ‘‘5,000 children between the ages of 3 and 17’’ suspected of carrying presumed hereditary disorders ‘‘were put to death’’ (p. 257). However, they did not name any of the psychiatrists involved in these programs, and failed to mention the involvement of German psychiatric geneticists such as Rudin. This also occurred in the 1998 book Psychiatric Genetics. Here, psychiatric genetic researchers Nurnberger and Berrettini wrote that the ‘‘low point’’ of the history of eugenics ‘‘was during the Nazi era, when eugenic theories were used to justify the mass murder of people with schizophrenia and mental retardation as well as ethnic ‘inferiors’’’ (Nurnberger and Berrettini, 1998, p. 129).

In the process of attempting to validate psychiatric twin research in their 2010 book How Genes Influence Behavior, Category A psychiatric genetic researchers Flint, Greenspan, and Kendler ignored the numerous critics of psychiatric twin research and instead focused on Kamin’s (1974) critical analysis of IQ genetic studies, including studies of twins. For Flint and colleagues, Kamin’s ‘‘diatribe’’ was another example of the danger of ‘‘the mixing of politics with science that always seems to accompany these studies’’ (Flint et al., 2010, pp. 26–27). They cited the rise of the eugenics movement as another example of the supposed hazard of mixing science and politics, regrettably (in our view) linking the ‘‘politics’’ of this steadfast opponent of eugenics (Kamin) to the politics of the eugenics movement and Nazism. ‘‘The ultimate embodiment of eugenics,’’ wrote Flint et al., ‘‘came under the National Socialist (Nazi) program in Germany, starting with the compulsory sterilization of mental patients (modeled after US statutes) and ending with the Final Solution’’ (p. 27).

Like other Category A ‘‘insider’’ historians, Flint and colleagues failed to mention the fact that German psychiatric genetic researchers –- such as the founder of their discipline Ernst Rudin –- were instrumental in creating the conditions for and providing a scientific stamp of approval to the atrocities of the Third Reich. In fact, Rudin personified the ‘‘ultimate embodiment of eugenics’’ in Hitler’s Germany.

Category B

The Category B position acknowledges that Rudin helped promote eugenic sterilization and/or may have worked with the Nazis, but generally paints a positive picture of Rudin’s research and denies or fails to mention that he supported the euthanasia program or that he supported anti-Semitism and the fight against the ‘‘parasitic alien races such as the Jews and Gypsies’’ (Category B authors include Cardno and McGuffin, 1999; Farmer, 2003; Farmer and McGuffin, 1999; Gottesman, 2008; Gottesman and Bertelsen, 1996; Kendler and Prescott, 2006; Shorter, 1997; Stromgren, 1994; Zerbin-Rudin and Kendler, 1996). Gottesman and Bertelsen ended their publication with a quotation from Rudin’s former Munich co-worker and racial hygienist Franz J. Kallmann, who wrote a letter in support of Rudin for the latter’s denazification hearing, claiming that Rudin ‘‘is no criminal, of course.’’ Gottesman and Bertelsen concluded, ‘‘We are content to let Kallmann have the last word for now’’ (Gottesman and Bertelsen, 1996, p. 321).

This contrasts sharply with the Swiss government’s ‘‘last word’’ on Rudin only 5 days after the German government’s capitulation in May, 1945. According to the Swiss authorities, they decided to revoke Rudin’s citizenship for both his scientific activities and his ‘‘pronounced political role’’:

Rudin belongs definitely to the intellectual leadership circle of the National Socialist regime. He was the expert who prepared the German racial-political legislation which brought immense suffering and ruin for millions of innocent people. Besides his scientific activity he, therefore, played a pronounced political role. Rudin’s life work contradicts the laws of humanity… (quoted in Weingart et al., 1988, p. 569, our translation)

In a Category B account by Zerbin-Rudin and Kendler (1996), the authors attempted to legitimize Rudin and his schizophrenia family research conducted before the Nazi seizure of power, as well as other psychiatric genetic research conducted during the Nazi era. This article caused considerable controversy, and led to some of the Category C responses we will see below. Zerbin-Rudin and Kendler wrote that ‘‘Rudin and his institute became involved in the eugenic policies of the Nazis,’’ though they saw this only as an example of the ‘‘possible political abuse of scientific findings in general and those from the field of psychiatric genetics in particular’’ (p. 332). Although the authors believed that the ‘‘relationship between Rudin and his institute and the racial and eugenic policies of the Nazi party after it came to power in Germany is an historically important subject’’ (p. 335), they declined to discuss Rudin’s activities during this period (while referring their readers to Weber’s 1993 biography of Rudin). According to Zerbin-Rudin and Kendler, many research psychiatrists were uninformed about ‘‘the extensive continental tradition of psychiatric genetics’’ for two main reasons: (1) ‘‘a language barrier,’’ and (2) ‘‘a rather virulent form of ‘presentism,’ (the tendency to value only recent endeavors and neglect the work of previous eras)’’ (p. 332).

In a book he co-authored 10 years later, Kendler mentioned the work of Luxenburger and Siemens without mentioning their strong support for racial hygienic policies both before and after the Nazi seizure of power, and discussed German psychiatric genetics and Rudin as follows:

In its infancy, psychiatric genetics -– under the leadership of Ernst Rudin (whose critical contributions to the birth of this field were colored by his dealings, later in life, with the Nazi party in Germany) –- was at the forefront of the methodological developments of the emerging field of human genetics. (Kendler and Prescott, 2006, p. 13)

We have seen that Category A and B authors sometimes allow that psychiatric genetic research was used by the Nazis, falsely implying that Rudin, Luxenburger, Schulz and others did not support the racial hygienic policies of the regime, and that their research was merely misused by others (for examples of this argument, see Faraone and Biederman, 2000; Faraone et al., 1999). Cardno and McGuffin (1999) went further and wrote, erroneously, that Schulz and Luxenburger opposed Nazi eugenic policies ‘‘on both moral and scientific grounds’’ (p. 344). A variation on this theme is the implication that Nazi-era psychiatric genetic researchers were judged to have committed no crimes, but ‘‘suffered from a sort of guilt by association’’ with the regime (Farmer, 2003, p. 428; Farmer and McGuffin, 1999, p. 483). Category A and B authors at times mention that Rudin was convicted only as a ‘‘fellow traveler’’ of the Nazi regime at his denazification hearing after the war (he received only a small fine), implying that he already had his day in court and that he committed no major crimes (e.g., Farmer and McGuffin, 1999). Gottesman and Bertelsen suggested that contemporary re-evaluations of Rudin based on new evidence amounted to a form of ‘‘double jeopardy’’ (being tried twice for the same crime; Gottesman and Bertelsen, 1996, p. 317). But in fact, Rudin was one of numerous Nazi scientists with blood on their hands who were allowed to escape justice after the war and continue their academic careers (Proctor, 1988).

While Category A and B authors fail to mention Rudin’s support of the Nazi persecution of the Jews, some (including researchers who trained, or whose mentors were trained, at Rudin’s Munich institute) implied that Rudin was not anti-Semitic and at times even helped protect Jews (e.g., Gottesman and Bertelsen, 1996; Stromgren, 1994). In an interview he conducted with Edith Zerbin-Rudin, Murderous Science author Benno Muller-Hill asked Zerbin-Rudin if her father was an anti- Semite. She responded, ‘‘No, not at all’’ (Muller-Hill, 1998, p. 132). A 1994 publication by Munich-trained Danish psychiatric geneticist Erik Stromgren provides additional evidence that the historical accounts by Rudin’s former students and collaborators are unreliable. Stromgren’s account finds Rudin and others attending the 1935 funeral of noted Munich researcher Walther Spielmeyer, despite the ‘‘nasty’’ weather that day. Stromgren then wrote, ‘‘I mention this incident in particular because it was quite remarkable that although Spielmeyer was a Jew, everybody wanted to pay him the last tribute’’ (Stromgren, 1994, p. 406). In fact, Spielmeyer was not a Jew, although he faced harassment because his wife and child had Jewish relatives (Weiss, 2010).

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Part 2 of 2

Category C

The less frequent Category C type of psychiatric genetic writer sees Rudin, in the words of Lerer and Segman, as ‘‘a man who was not only a willing accomplice to the most abhorrent crimes against humanity but an enthusiastic theorist who provided the intellectual basis for many of these crimes’’ (Lerer and Segman, 1997, p. 459). These researchers concluded,

There can be only one justification for the name of Ernst Rudin appearing in a contemporary scientific journal and that is to enable a generation of researchers who may not be fully aware of his tainted legacy, to learn more about it and to appreciate how easily science can be perverted in the service of evil. (p. 460)

Other psychiatric genetic researchers have written about Rudin as an architect and accomplice of unspeakable crimes against humanity (e.g., Baron, 1998; Gejman, 1997; Gershon, 1997; Propping, 2005; Schulze et al., 2004). Authors such as Baron, Gejman, Gershon, and Lerer and Segman did not set out to write a history of their field, but were mainly reacting to what they saw as the ‘‘whitewash’’ (Gershon, 1997, p. 457) perpetrated by colleagues such as Zerbin-Rudin and Kendler (1996) and Gottesman and Bertelsen (1996). In his comment on Zerbin-Rudin and Kendler’s claim that Rudin’s work was not well known due mainly to language barriers and persistent ‘‘presentism,’’ Gershon wrote, ‘‘By putting it this way, this article ignores the disrepute into which this discipline fell all over the world for many years, in no small part because of the misuses of science by prominent scientists in the field, such as Ernst Rudin’’ (Gershon, 1997, p. 457).

According to Gejman, ‘‘in all probability chronically ill patients from the families that Rudin used in his epidemiological research were murdered in the T4 euthanasia program’’ (Gejman, 1997, p. 456). The same holds true for subjects in other studies conducted by Munich school researchers such as Luxenburger and Schulz. Baron also weighed in on this point:

Given the scope of this hideous program and its focus on the genetically unfit, it is highly likely that Rudin’s own research subjects -– thousands of patients and family members were enrolled in his programs –- were among those who fell prey to the evil he helped inculcate. The information he collected could readily be put to malevolent use. … he compiled a vast data bank (on the order of tens of thousands of families) in order to calculate Mendelian ratios, based on information obtained from hospitals, asylums and other institutions. (Baron, 1998, p. 97)

Because Rudin participated in and supported the T4 ‘‘euthanasia’’ program while possessing detailed records of the families of people diagnosed with schizophrenia and other conditions, it is indeed likely that he provided this information to help identify and kill the people he and his colleagues had studied. As the German psychiatrist Uwe Peters described it, ‘‘Like a spider in the center of its net, all strings of information and power came together in [Rudin’s] hands’’ (Peters, 2001, p. 300).

But even Category C authors are not immune to revisionist accounts. In his book on the evolution of psychiatric genetic thought, Mellon wrote, ‘‘The role of the founders of modern psychiatric genetics in the sequence of events leading to mass murder is most troubling. Ernst Rudin was an early and vocal proponent of eugenic applications to mental problems. …his contribution to the series of events that helped lead to the exterminations is unmistakable’’ (Mellon, 1996, p. 112). At the same time, based on Slater’s 1971 account, Mellon mistakenly claimed that ‘‘in contrast to Rudin,’’ Luxenburger and Schulz ‘‘managed to stay out of the mainstream eugenic movement’’ (p. 113). The fact remains that Luxenburger supported and helped implement the eugenic policies of the Nazi regime (Joseph, 2004), and according to a 1934 report by the Danish eugenicist Tage Kemp, Schulz was ‘‘doing a great deal of statistical work concerning mental diseases of practical value for the sterilization law and the eugenical legislation in Germany’’ (quoted in Black, 2003, p. 419). In the late 1930s Rudin and his institute formed an alliance with Heinrich Himmler’s dreaded SS (Schutzstaffel; Weindling, 1989; Weiss, 2010), and in a memo Rudin assured a leader of the SS Ahnenerbe that although Schulz was not ‘‘a flaming National Socialist,’’ his usefulness to the SS could be assured without reservation (Weiss, 2010, p. 164).

In Baron’s (1998) otherwise important review of Rudin’s crimes, where he wrote that ‘‘Rudin played a central role in inspiring, condoning and promoting forcible sterilization and castration of schizophrenics’’ (p. 96), he implied that Rudin’s former associate Franz Kallmann discarded his hard-line eugenic beliefs after he had been forced to leave Germany in 1936 because of his partial Jewish ancestry. In 1935, while still active in Germany, Kallmann had called for the forcible sterilization of the healthy (yet presumed ‘‘schizophrenia taint carrier’’) family members of ‘‘schizophrenics’’ – a proposal rejected as too radical even by Kallmann’s racial-hygienicist colleagues who strongly supported the sterilization law (Muller-Hill, 1998). Although Baron discussed Kallmann’s 1935 support for the compulsory sterilization of family members, he wrote, ‘‘while in the USA, Kallmann recanted his early position on this matter and proceeded with perseverance and dedication to develop one of the finest academic programs in modern psychiatric genetics’’ (Baron, 1998, p. 99). However, Kallmann’s eugenic views, though adapted to a new country and post-war revelations of Nazi crimes committed in the name of eugenics and racial hygiene, remained largely unchanged until his death in 1965 (Joseph, 2004).

After being forced to leave Germany in 1936, Kallmann established the field of psychiatric genetics in the United States at the New York State Psychiatric Institute at Columbia University, based largely on the racial hygienic methods and theories he had learned in Rudin’s Munich school. At the same time, Kallmann remained a strong supporter of eugenics and compulsory sterilization (Kallmann, 1938a, b). Upon his arrival in the United States, Kallmann wrote, ‘‘The recommendation of negative eugenic measures against the carriers of any mental disease is genetically justifiable’’ after meeting certain criteria. Kallmann then wrote that ‘‘the schizophrenic disease process’’ meets these criteria (Kallmann, 1938b, p. 105). Clearly, in addition to people labeled schizophrenic, the ‘‘healthy’’ biologically-related ‘‘carriers of mental disease’’ were targeted by Kallmann for the application of ‘‘negative eugenic measures’’ such as sterilization. He called for ‘‘systematic preventative measures among the tainted children and siblings of schizophrenics’’ (Kallmann, 1938b, p. 113), because ‘‘we cannot expect sufficient success from the prevention of reproduction in the symptom-carriers alone’’ (Kallmann, 1938a, p. 4). This suggests that his 1935 position in favor of eugenic interventions directed at the family members of people diagnosed with schizophrenia remained largely in place, although by now he would not support the compulsory sterilization of these relatives, despite ‘‘the menace involved in the propagation of heterozygotic taint-carriers’’ (see Kallmann, 1938a, pp. 68–69).

Moreover, Kallmann published an annual review in the American Journal of Psychiatry from 1944 until his death in 1965, entitled ‘‘Heredity and Eugenics.’’ Themes of Kallmann’s annual updates included positive references to eugenic theories and policies, the alleged benefits of the compulsory eugenic sterilization laws then existing in many U.S. states (e.g., Kallmann, 1947, p. 515; 1951, p. 505), and discussions of Nazi genetic researchers Rudin and Verschuer in a positive light (e.g., Kallmann, 1952, 1953).

Two Articles by Ploetz and Rudin in Praise of Adolf Hitler and his Policies

We present below translations of two articles co-authored by Ploetz and Rudin in the same 1938 edition of Archiv fur Rassen-und Gesellschaftsbiologie (all emphasis in these documents was provided by Ploetz and Rudin). Both Ploetz and Rudin had become members of the Nazi party a year earlier (Proctor, 1988). The articles appeared 5 years after the Nazi seizure of power, and shortly after German troops had entered Austria with little resistance and had incorporated that country into the German Reich (the Anschluss). After the German takeover of Austria, the Nazi rulers held a national referendum in that country on April 10th, 1938 under conditions of terror, intimidation, and the persecution and imprisonment of Jews, Social Democrats, trade unionists, and leftists, on whether Germany and Austria should be united (Shirer, 1960). The Nazi government claimed that 99.75% of the Austrian people voted ‘‘Yes’’ to the unification of Austria and the German Reich.

The First Article

The article translated below (Ploetz and Rudin, 1938b) is entitled ‘‘On the Development of the German Reich since our Fuhrer’s Takeover of Power on January 30, 1933’’ (Zur Entwicklung des Deutschen Reichs seit der Machtubernahme unseres Fuhrers am 30. Januar 1933). The article was ‘‘addressed mainly to our foreign readers,’’ which suggests that Ploetz and Rudin toned down the rhetoric and attempted to convince potentially skeptical foreign readers of what they viewed as the achievements of psychiatric genetics, racial hygiene, and the Nazi regime.

We should emphasize that Ploetz and Rudin, though discussing Nazi government policies which they wholeheartedly supported, described what they viewed as the achievements of ‘‘our field of racial and social biology as well as racial and social hygiene.’’ They portrayed compulsory eugenic sterilization, the Nuremberg laws, and the vicious repression of ‘‘the Jewish part of the population’’ as scientific policies which they proudly played a role in helping implement.

The paragraph on the ‘‘racially upward movement’’ promoted by German foreign policy, in addition to the final devoted praise of Hitler, should forever lay to rest what remains of the myth that Rudin and his associates were apolitical scientists (see Roelcke, 2006). Ploetz and Rudin ended by writing that Hitler, one ‘‘of our greatest leaders since ancient times,’’ was ‘‘loved so passionately by his entire people.’’

On the Development of the German Reich Since Our Fuhrer’s Takeover of Power on January 30, 1933

In this short review, addressed mainly to our foreign readers, it is only possible to point to the most important advances that have occurred directly or indirectly in our field of racial and social biology as well as racial and social hygiene, a field that was designated by Adolf Hitler as the most important foundation of our life as a people and a state.

The reforms began with the passing of the Law for the Prevention of Hereditarily Diseased Offspring (July 14, 1933). According to this law, anybody who is hereditarily diseased can be sterilized with a surgical intervention or by other means, if according to the experiences of medical science it can be expected with a high degree of probability that his offspring will suffer from severe physical or mental hereditary defects.

The Law for the Protection of German Blood and German Honor followed the above-mentioned law (September 15, 1935). With this law, marriages or extramarital sexual intercourse between Jews and citizens with German or related blood were banned.

This was followed by the Law for the Protection of the Genetic Health of the German People (the matrimonial health law) of October 18, 1935. According to this law, a marriage cannot be entered into if one of the partners suffers from an infectious disease that raises the fear of significant damage to the health of the other partner or the offspring; if one of the partners is legally declared incapable of managing his own affairs or is put under temporary guardianship; if one of the partners, without being declared incapable, suffers from a mental disorder that makes the marriage appear undesirable for the national community, and if one of the partners suffers from a hereditary illness according to the Law for the Prevention of Hereditarily Diseased Offspring. People who are engaged to be married must provide a certificate from the department of health before the wedding to prove that there is no impediment to the marriage according to the law.

The careful execution of all these laws has been made easier and possible by supplements, decrees, and commentaries. Out of the application of these laws among the people have emerged streams of beneficial effects, effects that will only unfold in their full power in the near and especially in the distant future.

Further racial-hygienic measures were the numerous low interest bank loans for newly married couples and child benefits for families, particularly those with many children. These measures have led to a significant increase in the number of German births, which had been in considerable decline.

The education of the German youth in mental, spiritual, and physical respects continued and continues to be implemented under the leadership of the state, more and more independently of religious or racially alien management. In this way, the growth and preservation of the National Socialist spirit, already deeply influenced by state and party organization, is permanently guaranteed.

The Jewish part of the population that once had such strong influence, and even dominated our cultural and political life, has been strongly forced back, for example in the military, in the economy, among professional judges, among teachers of all kinds and levels, in the media, in theater, in film.

Unemployment, that was such a heavy burden on our people, has been reduced to a relatively insignificant number, and the condition of the working classes in general was lifted significantly in health, economic, and social respects.

The security of our people in its racially upward movement was further promoted by the resignation from the League of Nations, the bold declaration of the Treaties of Versailles and St. Germain as null and void, steps which enabled powerful measures of protection for the German Reich, such as the creation of a large modern military, the decisive occupation of the Rhineland through the entry of German troops, the German–Japanese–Italian Alliance against Communism and the creation of the German Reich–Italy ‘‘Axis’’ and, finally, the miraculous reunification of Austria with the German Reich, which not only meant a considerable increase of military, economic, and cultural opportunities, but above all realized the ancient longing of Germans in the Reich and in Austria to melt together forever and for all times into one Greater Germany.

These are some of the main parts of the giant work of our Fuhrer and his loyal supporters!

Hitler moves through his deeds into the rank of our greatest leaders since ancient times!

Our nation has understood this and is devoted to him with grateful hearts. No German prince, no German king or emperor has ever been loved so passionately by his entire people as Adolf Hitler.

Adolf Ploetz.
Ernst Rudin.

***

The second article (Ploetz and Rudin, 1938a) consists of a brief message of congratulations to Hitler on the occasion of his 49th birthday and of his successful annexation of Austria and the formation of ‘‘Greater Germany.’’

On the Occasion of Adolf Hitler’s Birthday

On April 20th our Fuhrer will be 49 years old, 10 days after a plebiscite in the old Reich and Austria, which brought him the unheard-of total of over 99% yes votes of the votes cast.

Everyone who witnessed the enthusiasm of our nation or who heard the reports of his friends in the former Reich and Austria about the vote knows that the spiteful and suspecting voices about the honesty of the vote belong in the realm of grey fantasy. If ever our nation (other than an extremely small portion) was perfectly united, it was the case this time.

We wish Adolf Hitler from the bottom of our heart that it may be granted to him by fate to continue to lead Greater Germany to the bright heights of peaceful development!

Alfred Ploetz.
Ernst Rudin.

Conclusion

The 1938 publications by Ploetz and Rudin that we have translated for this article provide additional evidence that Rudin (as well as Ploetz) was a strong supporter of Hitler and his criminal policies. And as others have documented, Rudin and others worked hand-in-hand with the National Socialist regime to implement and promote these policies, including the killing of mental patients and children for the purpose of eliminating the perceived genetic threat to the German Volkskorper (people’s body). Whether Rudin reluctantly aided and helped implement the ‘‘euthanasia’’ killing program, or whether he saw it as the crowning achievement of his decades of psychiatric genetic research based on racial hygienic (eugenic) principles, is an issue that may be decided in the future when more documents become available.

Regardless of his motivation, Rudin chillingly wrote in 1942 that the anticipated German victory in the war ‘‘will only inspire us…to multiply our racial hygienic efforts’’ (Rudin, 1942, p. 322). The launching of Rudin’s Munich institute in 1928, in the words of the President of the Kaiser-Wilhelm Institute, was ‘‘the starting point of a new epoch in healing’’ patients (quoted in Weiss, 2010, p. 124). It ended as an institute that played a role in the killing of mental patients and children.

A historian of Nazi-era medicine, William E. Seidelman, wrote in 1996 that ‘‘Rudin’s work on the genetics of schizophrenia, which established a theoretical basis for his eugenics work, continues to be cited in psychiatric genetics without reference to his eugenics career’’ (Seidelman, 1996, p. 1465). Although we have noted the contributions of the Category C authors, the leaders of psychiatric genetics have failed to produce a detailed (albeit ‘‘insider’’) complete account of their field’s history. We look forward to the publication of such a work.

Acknowledgments

We would like to thank Volker Roelcke, Claudia Chaufan, and Thomas Teo for providing helpful feedback on earlier drafts of this paper. All opinions and conclusions expressed in the present article are those of the authors only, and we take full responsibility for any errors in the text.

_______________

Notes:

1 We refer to a compulsory eugenic sterilization program as a crime regardless of whether it was sanctioned by law (as it was in Germany, the United States, Scandinavia, and elsewhere). Many other crimes of the Third Reich, such as the Nuremberg Laws, were also carried out according to the law. In addition to the dangers inherent in the surgical process, the procedure involved depriving people of the right to procreate children and undoubtedly caused many victims to experience a lifetime of emotional suffering. In the words of psychiatric genetic researcher Myron Baron, ‘‘What greater harm is there than maiming (sterilization or castration) or murder?’’ (Baron, 1998, p. 97). When we consider that the alleged scientific justification for the procedure was in most cases based on very weak evidence (see below, and see Joseph, 2004, 2006), the magnitude of the crime becomes much greater.

2 Although a solid case can be made in support of Propping’s ‘‘slippery slope’’ from  sterilization to killing characterization, others might argue that whereas eugenic sterilization was legal in Germany, no law was established sanctioning the euthanasia killing program, and that the programs followed a different logic. A prophetic opponent of sterilization who did see a logical progression from sterilization to killing was Swedish Socialist Party member of Parliament Carl Lindhagen, who objected to a 1922 proposal to enact a eugenic sterilization law in Sweden. Lindhagen stated, ‘‘Why shall we only deprive these persons, of no use to society or even for themselves, the ability of reproduction? Is it not even kinder to take their lives? This kind of dubious reasoning will be the outcome of the methods proposed today’’ (quoted in Broberg and Tyde´n,  2005, p. 104).
 
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