History of Behavioral Interventions in STD Control

STDs comprise a wide variety of pathogens, including viruses, bacteria, fungi, and protozoa, along with an equally broad range of clinical manifestations, from mild infections localized to the genitalia to more serious diseases affecting reproductive health, the central nervous system, heart, or the immune system. The fundamental reason for placing these diverse biological agents and their sequelae under the same category of STDs is that they share a common mode of transmission—that is, a common human behavior. Given that the category of STDs is defined according to a common behavior rather than a common biological pathogen or sequela, one would expect behavioral interventions to have been at the center of historical and current strategies to prevent and control STDs. Historically, however, the opposite has been true: compared with epidemic infectious diseases such as plague and cholera, which garnered significant public health attention, STD control was relegated to private physicians and largely ignored by public health officials, except for behavioral efforts aimed largely at “marginal” groups such as prostitutes or military personnel. This chapter explains why behavioral interventions for STD control have been a relatively neglected area of public health programs.

It should be noted that the term “behavioral interventions” has come into use relatively recently (since the 1980s), while behavioral science itself is a 20th-century creation. To avoid the anachronistic practice of imposing modern categories onto the past, it is important to explain past practices within their own historical context. The categories that people in the past used to describe and explain their STD prevention and control activities often developed from fundamentally different conceptions of disease transmission, public health, and human behavior. I have retained the original language (the “pox” instead of syphilis, if that was the term commonly used) to underscore the need to understand disease control efforts in context. Similarly, depending on the context, I will refer to the historic terminology used to characterize populations, groups, behaviors, and diseases, such as prostitutes rather than commercial sex workers.