Contraception/Chapter 13

Instruction in many of the subtleties of normal sex-life, and the physiological and psychological aspects of the controlled sex-congress in human beings should naturally form one of the more important themes of the education of medical students in all medical schools. Nevertheless in Britain (at any rate in the last generation or two) this subject has been so neglected that the majority of doctors who are now qualified and practising have received nothing in the form of training or instruction in contraception in the whole of their college courses. Such letters as the following testify not only to this fact, but to the deprivation which the practising medical feels when he comes in direct personal contact with the innumerable lives among his own patients whose health and happiness are jeopardized for want of such knowledge as he should have been trained to hand on.

​No. 1002 (An M.B. and Ch.B.). "It is the fact that during the whole of my University training for my profession the subject of the control of conception was never mentioned. It seems to have been left for you to make this—in many cases necessary knowledge—available in a form suitable for the lay mind as well as the professional."

No. 1004 (an M.D.) "Although a medical man of some experience and supposed to be well-informed on these matters, I realize that I knew very little."

No. 1003. "Will you be so kind as to tell Dr. —— a method of birth control. He believes in judicious control in many cases but he only knows of the sheaths for men."

No. 1006 (an M.B., Ch.B.). "Although I am a medical man, at the time of my marriage five years ago (1915) I knew little or nothing of the abstruse problems of sex. During my medical course, at one of the most famous British schools, I received no instruction whatsoever on this subject—apart of course, from the ordinary training in midwifery and gynecology, I should be obliged if you could give me your opinion as to the most hygienic and safe means of controlling pregnancy, as I am ​frequently consulted on this subject and often feel at a loss as to what to advise."

No. 1051 (an M.B.) "Recently I gathered the only scientific knowledge of the subject of contraceptives which I possess from your 'Wise Parenthood.' As you are aware medical men have about as small a chance of acquiring such information as have the general public."

No. 1053 (an M.B.). "I take the liberty of writing to ask you what are the methods you advise in your Clinic? I have in my mind a case of two consumptives just married in whom I take an interest (patients of mine). They do not wish to have children for fear the disease, or tendency to it, should be transmitted. If you could let me know the means you use to prevent this I should be greatly obliged and keep it secret. I am a country practitioner of twenty years' standing."

No. 2045 (an M.D.). "Would you be so kind as to see a patient of mine at your Clinic and to give her some advice (or contraceptives). I have no idea where she should go."

No. 200? (a medical woman). "In two years I have had three children and a fractured patella and I feel a physical and mental wreck. My husband and I are both ​doctors but we seem to be hopeless ignoramuses on this subject."

No. 101. (a medical practitioner). "I have just finished reading your interesting and instructive book 'Married Love': although a practitioner of twelve years, and a married man with four children, it has taught me many things I did not know before and concerning which many of our profession are ignorant. A question frequently asked in private practice is 'what means of prevention do you advise?' I have always advised coitus interruptus. You are evidently strongly of opinion that this has harmful effects, which are clearly pointed out in your book. [See fuller account p. 69 ante.] I would like to hear what method you consider most suitable."

No. 2023 (An M.R.C.S., L.R.C.P.). "Can you give me any help as to what answer to give my patients who ask as to the best and safest preventative? That question I get frequently and for a time I advised the simple douche but some patients and my own wife found it not reliable." [See p. 116 ante.]

No. 510 (a medical practitioner). "I have frequently to advise patients upon the subjects dealt with in your books, and am only too well aware how little we medical ​then know with any degree of authority how to deal with such inquiries. It seems good for the public (even if a reflection on us medicals) that your work should have come from a biologist, rather than from 'pathological' sources. We medicals are forced in the present state of affairs to be menders of the broken rather than preventers of the breakages."

No. 2011 (an M.D., F.R.C.S.). "It will be very kind of you if you will help me. My son, who is about to marry, wants to act on your advice [re contraceptives] . . . I am rather at sea in such matters."

I have received hundreds of such letters and questions from fully qualified medical practitioners; but these should be sufficient to illustrate the fact that there is not merely a popular demand for instruction in contraceptive means but also that the medical profession itself as a whole lacks, and feels the lack, of such instruction. It must be, therefore, with mixed feelings that one reads Lord Dawson's preface to his pamphlet^[1] wherein he says: "I have discriminated between the principle of birth control and the method of its application, the latter being preferably determined by the advice ​of the family doctor rather than by the perusal of books in general circulation." True but it would have been more just to have added that a very large number of medical practitioners have but recently derived their information from a book "in general circulation," viz., "Wise Parenthood."

It is possible that in some medical schools there has been individual instruction in contraception in the past, but I have not yet been able to find any record or any direct evidence of it except one verbal statement when lecturing on contraceptive methods recently (1922) to the Medical Society of Charing Cross Hospital Medical School, my Chairman then said he had always given some instruction to his students incidentally as suitable opportunities arose in connection with their work. I should be glad to receive any other authenticated records of the same sort as I hope to be able at a later date to give a fuller history of the subject.

Since the publication of "Married Love" (1918) sporadically and unauthoritatively there have been isolated attempts at such instruction, and some lecturers have referred their classes to this book and to "Wise Parenthood." But the fact still remains ​very evident, that the training for the medical profession is generally based on the foundation of an assumption that the medical practitioner is a doctor of disease. Hence that it is necessary for him (or her) to be trained in all that appertains to every common and as many rare diseases as the college years permit. True preventive medicine has not yet reared its edifice on the firm rock of a thorough understanding of and training in the requirements of normal health. The proper use of contraceptives, as being the greatest safeguard of the race in preventing weakness, induced, and inherited disease, is not yet officially recognized in the Medical Schools, although in many subjects less tinged with feeling and surrounded by ancient taboos than those involved in sex matters, this newer and sounder attitude is being widely adopted.

In March 1922 I sent a special letter of inquiry to all the leading Medical Schools in Great Britain asking whether any classes or lectures on contraception were available for their medical students: most of these sent replies, either from their respective Deans or Secretaries and all (with one exception) replied with a categorical negative. A typical reply was as ​follows "The subject you mention is not included in our Prospectus, nor are lectures given on it by any of the Medical Lecturers or Professors." A big school replied "there are no classes or lectures on the subject of contraception for the students at this medical school, nor is it at present the intention of the authorities of the school to institute any classes or lectures on this subject." Another added, "I think I may say, that such information would not be required of students before their Final Examination, and for that they are prepared in the departments of Surgery, Medicine, Obstetrics, and Gynecology."

The one exception was particularly intriguing the Royal Free Hospital School of Medicine for Women replied "the question of the Prevention of Pregnancy is dealt with in the Obstetrical and Gynæcological Unit of the Royal Free Hospital when the occasion for the necessity of its discussion arises." As this, therefore, appeared to be the only enlightened Medical School in our country I wrote again and received the personal reply of Professor Louise McIlroy that "There are no special classes held on the subject of Birth Control In the School. The question of the prevention of pregnancy is dealt with in indi​vidual cases of patients, and the students are instructed accordingly." In connection with this one must note Professor McIlroy's lecture on contraception^[2] and also that more recently there have been widely reported in the ordinary press her other pronouncements of opposition to the general spread of knowledge of contraceptives.

No science is more swayed by public opinion and guided by public demands than Medicine, and there is every hope that as the great public awakens to the need for instruction in normal healthy sex procedure so will it become possible for research into normal behaviour to establish a true Faculty of Preventive Medicine. This must be grounded on the very basis of all true ante-natal preventive work (important though that be) and goes really to the root of the matter by securing for the community, almost without exception, that conceptions shall be potentially healthy and favourable, or shall not occur.

Regarding the actual 'instruction in medical schools in this subject, as I have had a good deal of experience of academic ​teaching in the Universities,^[3] one or two simple suggestions resulting from that experience may be useful.

In order that undergraduate students should take the subject seriously, it is necessary that it should be specifically named in the syllabus of all the Medical Schools. It should, I think, occur both in the groups of subjects under Preventive Medicine, and also Gynæcology. There should be a question on some aspect of contraception in one of the examinations every year or two, or the students will not set themselves to master the details.

Ideally the subject should be considered in a full course dealing with all the leading physiological and psychological reactions of normal healthy persons in marriage. Some day this may be possible, it is not at present.

Meanwhile were I asked at once to plan an adequate course of instruction for the syllabus of a first-class medical degree I should stipulate that the students came for the special lectures on contraception after they had already assisted at at least two or three actual births, and hence had the ​necessary ground work on which to build the special detail required. There should then be not less than three lectures of one hour each illustrated by diagrams and the display of the actual preventive appliances. Thereafter each student should spend not less than six periods of two hours each at the birth control clinic working with the experienced midwife nurse and doctor in charge and thus gaining practice in the insertion of the necessary caps, &c., and also some understanding of the difficult cases which are of such frequent occurrence among the poor who have become to some degree abnormal through over-childbearing.

I well know how crowded college terms are; and the outcry always raised against any new intrusion into the packed syllabus, nevertheless, those training our future medical practitioners should bear in mind that there is no single health measure so important to the community at large as this.

Such a course is the minimum which in my opinion is essential for every medical practitioner to have passed through while training. Later on a more advanced course of lectures of "Intercollegiate" standard would probably be arranged from time to time for those specializing in either gynæcological or domestic practice.