Reproduction between Health and Sickness: Doctors’ Attitudes to Reproductive Issues in Interwar Czechoslovakia*

Veronika Lacinová Najmanová
University of Pardubice
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Hungarian Historical Review Volume 10 Issue 2  (2021): 301-327 DOI 10.38145/2021.2.301

The study examines how doctors in interwar Czechoslovakia intervened in reproductive issues and related areas of life in an attempt to combat the declining birthrate, a trend that was considered a threat to society. Inspired by Foucault’s concept of medicalization and biopower, through the analysis of medical literature and articles from the press in the interwar period, I will demonstrate how Czechoslovak doctors, not only but especially under the influence of eugenics, foregrounded the categories of health and sickness in order to assert definitions of “correct” forms of reproduction while attempting to stigmatize and discourage forms of reproduction that they considered detrimental to the health of society or the nation. The aim of the study is not only to expand the body of knowledge about the activities and attitudes of Czechoslovak doctors in the interwar period but also to call attention to the still current topic of the political background of reproductive policy.

Keywords: reproduction, medicalization, doctors, eugenics, birth control, interwar Czechoslovakia

“Reproduction cannot be left to mere urges; here too, rational considerations should play a decisive role. Reproduction is no longer merely a private matter. On the contrary—it is a matter of vital interest to society and the state.”1

These words were written in 1931 by the Czech doctor and biologist Vladislav Růžička2 in his book Eugenická profylaxa (Eugenic prophylaxis).3 Although reproduction may seem an intensely intimate matter, in the first half of the twentieth century (and indeed even today) it was not a purely private concern; human reproduction was subject to oversight and monitoring by various experts who, to a substantial extent, defined how people could and should reproduce without (allegedly) endangering the interests of society. Chief among these experts were doctors, who attempted to influence reproductive behavior, shape reproductive policy, and determine who should or should not have children and under what circumstances. In most cases, these doctors had the purest motives. They were striving to promote a healthy society and nation, and they considered themselves in possession of an authority emanating from science, which appeared to offer unlimited possibilities.

In this article, I will show that in the background of the attitude of Czechoslovak doctors to reproductive issues, especially abortion and contraception, we can find more a reflection of the political, social, and national problems of the interwar period and the efforts to face them, than a reflection of the state of scientific knowledge at the time. My theoretical and methodological approach draws on Foucault’s concept of power, especially the relationship between power and knowledge, and on the critical approach of feminist and gender studies, which were among the first to question the objectivity of the sciences, including medical science. Both approaches have made it possible in the past for historiography and branches of the social sciences to redefine or completely reject the earlier idea of the development of medical knowledge as a process moving from backwardness or ignorance to general wellbeing and progress. I consider the approach to history based on the deconstruction of power relations and including the perspective of not only privileged but also marginal social groups highly inspiring even today. In this article, therefore, I offer a critical analysis of the medical discourse on the issue of reproduction in an effort to reveal often less clear political (as well as religious, nationality, etc.) motives, which, as shown below, played a crucial role in doctors’ approaches to questions associated with reproduction. The sources on which my analysis is based capture both the professional medical (and eugenic) discourse and the efforts that were made to acquaint the general public with some of these ideas and their implications. The first group consists of articles published in professional medical journals, professional medical books, and textbooks and the second of materials which were essentially intended to serve as informational guides on sexual health, e.g., manuals for individuals or spouses, in which doctors shed light on various topics related to sexual life and reproduction.

The Role of the Doctor in the Medicalized World

The roots of doctors’ influence over reproductive issues and reproductive policy can be traced back to the Enlightenment, which saw the origin of processes that boosted the scientific prestige of medicine and enhanced the importance of the medical profession. It was also during the Enlightenment era that states began to strengthen their influence over medicine. Faced with a range of social changes, absolutist states realized the importance of their populations, and they began to implement new forms of control. States were keen to ensure that their populations were healthy and physically fit, and they also strove to maintain high population levels. Social control (including control of health-related issues) was substantially strengthened, and human reproduction ceased to be perceived as a merely a private matter. Instead, it became the concern of the state or society as a whole. States sought to ensure that their populations were large enough to provide a substantial labor force, produce an adequate supply of military recruits, and ensure sufficient economic demand. This led to the emergence of a doctrine known as populationism, which viewed the population and demographic behavior as central concerns of the state. The aim was not merely to maximize the size of the population, but also to ensure its “quality.” This approach made doctors increasingly important; in many countries (including the Czech-speaking provinces of the Habsburg Monarchy), the populationist doctrine was incorporated into the concept of state health policy.4

People and their bodies were newly subjected to systematic examination and supervision by the medical profession, which to a large extent became a tool for the implementation of state policy. The state was now responsible for the health of its population, and doctors were called on not merely to treat the individual bodies of their patients, but also to contribute to the wellbeing of society, which was viewed as a living organism. This set of changes, which accompanied the transition from a traditional society to a modern society, has been analyzed in detail by Michel Foucault5 from the perspectives of the concepts of medicalization and biopower.6 Thanks to the gradual medicalization of the community, a process in which medicine began to intervene in areas that had previously been felt to lie outside its domain,7 there was a significant change in the status of doctors, whose social prestige and influence increased significantly, but there was also a redefinition of the concept of health and disease. The health of society, analogous to the health of the individual, has become an ideal, and the notion of disease gradually evolved into a metaphor for everything that was deemed unnatural and therefore had to be fought against.8 Thanks to “the connection of the modern biopolitical disciplinary apparatus with the idea of defending society against ‘risk factors’,” a notion was created of a struggle against enemies that disrupt the health of society.9 These metaphors of sickness became increasingly aggressive, and the enemies they were used to construct also changed.10 What remained consistent, on the other hand, was the idea of medical science as a protector against them. Medicine integrated several socially undesirable phenomena, through their connections to the concepts of health and disease, into the sphere of its competence, which enabled it to exert its influence on them under the pretext of treatment. Doctors themselves often helped to construct these dangers and the associated enemies, fueling the fears thus evoked.11 These consequences of the medicalization of society can be deconstructed in relation to the declining birthrate and the associated fear of depopulation, a process resulting from the reproductive change that had affected many European countries, including Czechoslovakia.

A new dimension to the process of medicine’s entry into more and more social spheres came with the emergence of nation states and the related idea of so-called national health. Metaphors of health and disease blended with the concept of nation and national identity. Health concerns and eugenically motivated concerns about the “quality” of future generations penetrated the ethical and moral foundations of the whole project of nation building.12 The emerging states also sought to protect their national identities through public health and medical science, which was seen as having a dual role. First, it helped define the nation and national identity on a biological basis, and second, it oversaw a large area of public health. According to Promitzer, Trubeta, and Turda “one of the most important corollaries to this development was the physician’s extensive social and national involvement: a physician was now more than just a medical doctor caring for patients. He (and increasingly she) gradually became an instrument of state politics while medicine became a medium for addressing moral and ethical questions pertaining to the health of the nation and society.”13

Eugenics, Depopulation, and Degeneration

The growing influence of doctors not only on reproduction but on many other areas of human life was based not only on their role as protectors of national health, but also on the authority that science enjoyed in society. According to Robert Proctor,14 science represented a haven of certainty and stability in the turbulent, uncertain times around the turn of the twentieth century, when society and politics were gripped by chaos, and doubt was increasingly being cast on old certainties. The development of statistics and the increasing importance of classification as a method, which had become widespread in the sciences under the influence of Charles Darwin’s publications, made it possible “better” to measure, evaluate, and subsequently hierarchize people and social phenomena.15 The principles of statistics, genetics, and natural selection were also used to construct a (pseudo)science which came to play an important role in reproductive issues and reproductive politics: eugenics. Eugenics was a form of thinking which set out to combat unfavorable demographic trends and improve both the quantity and quality of the population by applying knowledge from genetics. It was developed during the final third of the nineteenth century by the English scientist Francis Galton; in simple terms, its aim was to breed people based on the principles of heredity and natural selection.16

Eugenic ideas spread throughout the world in the first half of the twentieth century, and although eugenics had its own specifics in different countries, we can indeed speak of a movement of ideas that affected a large part of the world in some form.17 Alongside England, the USA and Germany are considered to be the most important centers of eugenic thinking, but eugenic ideas held significant sway in Scandinavia and South America. Eugenics has also been echoed in Central and Eastern European countries, although, as Paul Weindling points out, eugenic ideas were largely influenced by national contexts, leading to great differences in the social and medical measures taken by eugenics. In the Czech-speaking provinces of the Habsburg Monarchy, eugenics began to take root at the beginning of the twentieth century, when the doctor and university professor Ladislav Haškovec18 started to organize various activities aiming to raise awareness of eugenics among both experts and non-experts. He canvassed doctors in an attempt to gain support for his proposal to introduce legislation requiring compulsory medical examinations prior to marriage.19 Česká eugenická společnost (Czech Eugenic Society) was founded in 1915. It cannot be said that all doctors in the interwar period were followers of eugenic ideas, nor is it true that all members of the Czech eugenic society were doctors,20 but eugenic discourse was widespread in the medical profession in the interwar period, and doctors formed a substantial part of the Czech eugenic movement.21 The close connection between medicine and eugenics applies not only to the Czech space. In the context of eugenics and racial science in Central and Southeastern Europe, there were mainly doctors who, according to Marius Turda and Weidling, helped to establish these ideological trends as modern scientific disciplines.22

Eugenicists also tried to establish themselves as a national movement in this area. Unlike the USA or Germany, where eugenics was strongly intertwined with racial theories and the central element of its discourse was the concept of race or ethnicity, in Czechoslovakia and Central and Southeastern Europe, the concept of the nation strengthened and was strengthened by the eugenics discourse.23 Eugenics became an integral part of the process of building a modern nation state.24 In Czechoslovakia, the protection of and support for the nation’s alleged biological quality was a central concern for the eugenic movement throughout the 1920s, and notions of national wellbeing underlay all eugenically motivated debates on reproduction and demographic issues in general.25 The motif of an impending threat to a small nation which is in danger of being absorbed by larger (and more fertile) nations is common in the context of eugenic discourse, as shown by this statement: “For small nations, it is particularly essential to ensure that the population remains at a certain level. A sharp drop in the population of any nation represents a threat to the very foundations of its existence, and all the more so if the nation is a small one.”26 This motif appears repeatedly the in medical literature and is one of the proofs of the influence of eugenic ideas on medical discourse. This idea appeared repeatedly in the medical literature of the period.

The statement cited above offers an example of the nationalist subtext of eugenic thinking in Czechoslovakia and a reference to one of the biggest problems with which eugenicists dealt, and not only in Czechoslovakia: the decline in birth rates and the related fear of depopulation. In the nineteenth century, most European countries (except for France, where this process began as early as the late eighteenth century) began to show signs of changing demographic behavior and a gradual decline in birth rates. The decline continued in the first half of the twentieth century, and fears of depopulation were exacerbated by the losses suffered during World War I. The low birthrate led to fears that there would be a shortage of men fit to serve in the military, and these fears were further stoked by the aforementioned nationalist or racialist concerns that the nation would die out or the quality of the race would suffer. As a consequence, concerns over the declining birthrate, the reduction of the population’s biological quality, and the waning desire to have children were leitmotifs running through most of the medical literature on this subject in the interwar years.

These anxieties concerning depopulation were not unfounded. Czechoslovakia had experienced one of the sharpest drops in the birthrate of any European country. Before World War I, the Czechs had the second lowest birthrate in the Austro–Hungarian Monarchy (after the Germans). In the interwar period, Czechoslovakia’s birthrate was somewhat boosted by the incorporation of Slovakia and the eastern province of Subcarpathian Ruthenia (now in Ukraine), where it was traditionally higher, yet the rate was still just 14.9 newborns per 1,000 people, an even lower proportion than in France, which was considered to be a cautionary example of depopulation because it was the first country where the birthrate had begun to decline.27 Despite this situation, Czechoslovakia’s interwar governments, although they repeatedly discussed the problem, did not adopt a comprehensive population policy and did not take comprehensive steps to encourage a higher birthrate; they merely introduced small-scale measures offering support to families in general, such as various financial benefits or the expansion of health insurance coverage.28 The worrying demographic trend during the interwar years thus offered fertile ground for various proposals seeking to increase the birthrate, criticisms of deliberate birth control, and the stigmatization of those who were thought to be contributing to the declining birthrate.29

Although the declining birthrate was a reality, doctors often played a key role in constructing it as an undesirable or even catastrophic phenomenon. According to Cornelie Usborn,30 who has studied reproductive policy in the Weimar Republic, doctors began to raise the alarm around the turn of the twentieth century, when the first major drop in the birthrate was recorded. They constructed a narrative of national crisis, ranking the declining birthrate among “illnesses” such as tuberculosis, alcoholism, and venereal diseases, i.e., illnesses which had to be treated before their impact on the organism of the nation became fatal. This was all taking place at a time when the declining birthrate was still being balanced out by the decline in mortality and thus was not yet causing the overall population to stagnate or fall.31 Miloslav Szabó, in his study of abortions in the Slovak part of Czechoslovakia, reached similar conclusions on the role of doctors in presenting the declining birthrate as a threat to society. In his opinion, the process of building the Czechoslovak state after the World War I was strongly affected by fears of a declining population, and texts by Slovak doctors, especially those intended for the general public, depicted an almost apocalyptic vision of the collapse of society, partly as a consequence of abortions.32

In addition to the fear of population decline, eugenic discourse was also based on the fear of an alleged decline in the quality of the population, which was reflected in the concept of degeneration and the problem of differential fertility.33 It is worth emphasizing, in this context, that convictions concerning the superiority of some people (or “peoples”) over others thus lay at the heart of eugenics from the outset. Eugenics followed an interpretation Darwin’s idea of natural selection according to which only the strongest survive in the struggle for life. The result was that at the very core of eugenics was the idea of biologically (genetically) determined inequalities among humans. The classification of people into groups which allegedly represented a healthy gene pool and groups which were allegedly genetically pathological and thus inferior was also reflected in attitudes towards reproduction, where the goal of so-called positive eugenics was to motivate “quality” individuals to give birth to more children, while the goal of negative eugenics was to reduce or prevent reproduction of allegedly inferior individuals. Differential fertility, it was believed, would lead to a reduction in the quality of the population, which could lead to degeneration and the extinction of the population.

Alongside anxieties concerning depopulation, the notion of degeneration became another element of the eugenic discourse, and it appears in the medical literature, in not as saliently. The most common definition of this fundamental concept in eugenicist discourse drew on the principles of Darwinism. According to these ideas, degeneration meant a descent to the lowest level of social development (in other words, the opposite of evolution), and in more general terms, it referred to the threat of physiological, psychological, and social decline. With regard to reproductive issues, degeneration was felt to be closely associated with a declining birthrate, and individuals or entire societies suffering from degeneration were felt to be characterized by a decreased ability to conceive, bear, and adequately provide for children. This process was seen as being manifested in the inability of men and (mainly) women to carry out their reproductive “duties” or, even worse, in their unwillingness to do so. Degeneration was presented as a form of societal decline, as something undesirable which had to be prevented, and also as a deviation of social progress from its correct path, a path that was frequently viewed as the only natural path. In this context, eugenicists created the notion that healthy people who for whatever reason refused to perform their reproductive role were in fact contributing to the decline of society and had to be corrected. It is worth emphasizing that this category of internal enemies consisted mainly of women,34 especially women who deviated from the traditional image of femininity, in other words emancipated women who were students or professionals, as well as women who deliberately restricted their fertility.35 This gender-conditioned denigration of a certain group of women who were viewed as disruptive to the social order due to their refusal to perform their reproductive role also appeared in the medical literature and was undoubtedly related not only to eugenics but, more generally, to the rigid approach of the medical profession to the social role of women.

Healthy Breeding to Save the Nation

Let us now turn to the Czechoslovak doctors’ attitudes to selected reproductive issues in the interwar period and how these attitudes were influenced by fears of the declining birthrate and other threats outlined above. The medicalization of reproduction and concerns about the future of the nation made it possible in the interwar period to create and maintain the idea that doctors were the most competent people to decide who should and should not have children. In the eighteenth and nineteenth centuries, the establishment of obstetrics as a new medical discipline offers one important example of doctors’ involvement and intervention in reproductive issues, and in the first half of the twentieth century, the medicalization of reproduction was reflected in issues of fertility control, in particular in the question of the permissibility of abortions and contraception.

In Czechoslovakia as in other European countries, the first half of the twentieth century was a time when legislation on abortion was a major subject of debate. There were various attempts to decriminalize abortion or to expand the range of circumstances under which an abortion could be carried out legally. The main reason why abortion became a focal issue for politicians and activists was the high number of illegally performed abortions and the complications that arose because of this practice, particularly the supposed negative effects on women’s health and the risk of damage to the fetus if the abortion was unsuccessful. It was later estimated that between 70,000 and 100,000 illegal abortions were performed annually in Czechoslovakia in the interwar period,36 only a very small percentage of which were discovered, mainly those that led to complications, forcing women to seek medical help or, in the worst cases, causing their deaths. The high number of clandestine abortions was due to the fact that they were illegal. It was a criminal offence both to undergo an abortion and to perform one. In 1918, the newly formed Czechoslovak state adopted the Austrian Criminal Code of 1852, Section 144 of which defined abortion as a crime and stipulated a prison sentence of between five and ten years. The only exception when an abortion could be performed legally was the existence of medical grounds in cases in which the mother’s life would be at risk if an abortion were not performed. However, the number of prison sentences imposed was far lower than the number of abortions actually carried out, and this helped motivate efforts towards decriminalization.37

In interwar Czechoslovakia, six amendments to the Criminal Code were proposed which would have decriminalized abortion, mainly by social democratic members of parliament (both of Czech and German nationality). The greatest support was enjoyed by a 1931 proposal submitted by the social democratic Minister of Justice Alfréd Meissner, which defined abortions as mere misdemeanors (i.e., not criminal offences) and specified circumstances under which they would be entirely legal. These circumstances included not only medical considerations but also social and eugenic concerns.38 The proposed amendment sparked widespread debate not only among experts (demographers, economists, and lawyers), but also among the members of the general public. Doctors played a key role in this debate, though the greatest point of contention between the proponents and opponents of decriminalization was not the definition of medical circumstances, but the social circumstances under which abortion was to be deemed legal. Most doctors did not dispute that in some cases it was necessary to perform an abortion on medical grounds. Devoutly Catholic doctors were an exception to this, as they considered any abortion whatsoever to represent the murder of an unborn child. If failure to perform an abortion endangered the mother’s life, they argued, her death in such a case would be worthy of admiration. The Slovak doctor Emanuel Filo,39 in his inaugural address after he was appointed to serve as the Rector of Comenius University in Bratislava, addressed the need to protect motherhood, quoting from Pope Pius XI’s 1930 encyclical Casti connubii (Of Chaste Wedlock), in which the Pope “expressed sympathy with those heroic mothers whose performance of their maternal duties threatened their health and lives.”40 Filo also rejected the notion that in cases in which the mother was seriously ill (e.g. with eclampsia) it was necessary to terminate her pregnancy. The difference in opinion between Slovak and Czech doctors, which was based primarily on a different degree of Christian conservatism,41 illustrates the fact that abortion was not viewed solely as a medical issue, even though doctors attempted to present it as such. Doctors were invited to participate in debates on abortion because they were seen as being able to contribute scientific expertise, conclusions, and recommendations to political representatives, but they were still frequently motivated by religious, nationalist, or entirely personal considerations. The economic aspects of abortion should also not be overlooked. In debates on the issue, the advocates of decriminalization sometimes criticized doctors for opposing the expansion of the range of circumstances that would allow abortions to be performed legally, accusing doctors of being motivated solely by a desire for personal enrichment, as clandestine abortions represented a source of income for them. Illegal abortions were not only performed by midwives, medical students, and unqualified quacks, but also by doctors, mainly for wealthy clients who could afford to pay substantial sums for their professional services and their discretion.

In general, in the interwar period, Czechoslovak doctors took a rather conservative approach to the issue of abortion.42 A large majority of them opposed any expansion of the range of circumstances under which abortions could be performed legally, insisting that the only permissible circumstances should be those involving a threat to the mother’s life or health. Medical associations were asked to issue statements of opinion on the various proposals for decriminalization, and they always opposed the proposals.43 The arguments against decriminalization mainly emphasized the health risks of abortions, even when the procedure was performed by a qualified professional in a proper health care facility. Doctors argued that their mission was to cure people, not to destroy life in its early phase, especially when doing so represented a substantial risk to the woman’s life or health. The socioeconomic reasons that were emphasized by the supporters of decriminalization, i.e., the argument that a woman should not be forced to bear a child for which she would be unable to provide care, thus bringing poverty and other difficulties upon her family, were rejected by doctors, who stated that it was not their role to assess their patients’ social situation. However, behind this stance one discerns the doctors’ fear that the acceptance of social or eugenic circumstances as valid reasons for performing abortions would lead to a dramatic increase in the number of abortions, accompanied by a further decline in the birthrate. The fear of depopulation was presented both explicitly and implicitly in debates on the legalization of abortions, and appeals to doctors not to force women to rely on the services of unqualified quacks were ignored. None of the proposals for decriminalization was approved, and it can be assumed that this was partly due to the stance taken by doctors (who were viewed as experts on reproduction and national health) combined with the emphasis on the health risks to the mother even in cases of abortions that were performed by professionals.

Contraception for the (Non)Wealthy Only

While Czech doctors’ stance on abortion remained relatively consistent throughout most of the first half of the twentieth century, their stance on contraception shifted substantially. In the first decades of the century, contraception remained something of a taboo subject, and it did not receive much attention from the medical profession. However, in the 1930s it moved increasingly to the forefront of the debate. This was probably partly due to the increasing sophistication of contraceptive methods, and it also reflected the widely discussed issue of abortions, as contraception was presented as a more desirable alternative to abortion. In the early years of the twentieth century, doctors generally opposed the use of contraception, taking the stance that the only acceptable form of birth control was sexual abstinence.44 Medical handbooks aimed at the members of the general public often contained passages on the irrevocable damage to health caused by the artificial restriction of fertility, and their authors also emphasized the risks that contraception posed to the morality of society. Bohuslav Horák,45 the author of the book Pohlavní zdravověda pro muže i ženy v manželství (Sexual health for men and women in marriage), which was issued in five editions within a period of thirteen years, made the following contentions:

The consequences of unnatural sexual intercourse, when care is taken to avoid impregnation, are very numerous, and often very sad too. Sicknesses of the body and nerves result, especially disorders of the sexual organs. Mental emptiness, an unwillingness to engage in normal sexual intercourse, which does not bring a pleasant sensation, leading to nervous disorders, especially hysteria in women.46

However, the situation changed in the 1930s, and doctors increasingly rejected sexual abstinence as a way of avoiding conception. It is telling that Bohuslav Horák used the word “unnatural” to describe sexual intercourse in which contraception is used, yet just a few years later, one of his colleagues, the renowned Czech gynecologist Antonín Ostrčil,47 used the same word to describe sexual abstinence. In a gynecology textbook for doctors and medical students, Ostrčil noted: “Sexual abstinence is often recommended for purposes of contraception […] That advice has absolutely no practical value, and is offered by people who either have not the slightest idea about human life or who are sexually abnormal […] so I consider it unnecessary even to consider this completely unnatural advice.”48 This shift, which reflects a shift in sexual morality, the gradual secularization of society, and the development of sexology again demonstrates that doctors’ opinions on what behavior was natural or unnatural (pathological and undesirable) were based not only on objective scientific knowledge but also on different motivations, which were cloaked in the terminology of health and sickness in order to lend them greater legitimacy and urgency.

This shift in doctors’ stance towards the notion of sexual abstinence as the only acceptable way to prevent unwanted pregnancy heralded the Czech gynecological community’s acceptance of contraception as a subject for discussion, and it is also reflected in the marked rise in the frequency with which contraception was mentioned in Czech medical literature. Nevertheless, it is not tenable to state that doctors became defenders or proponents of birth control during the 1930s. In fact, their stance was highly ambivalent, and they also took a selective approach both to the means of contraception and to the people who should use those means. Condoms were the first contraceptive device to be accepted by doctors; they were considered an important weapon in the struggle against venereal diseases. Alongside cervical caps, condoms were viewed by Czechoslovak gynecologists as the most effective ways of preventing unwanted pregnancies. At the lowest end of the scale in doctors’ preferences was the withdrawal method (coitus interruptus). This was undoubtedly the most widespread method of birth control (if we disregard abortion), mainly because it required no equipment and cost nothing. Despite this, or perhaps for this very reason, doctors considered it not only highly ineffective, but above all damaging to health. Without exception, all medical publications about contraception rejected coitus interruptus as an entirely inappropriate and harmful method of birth control. Of course, the question is whether doctors’ aversion to this method was based on genuine knowledge about its supposed negative effects on health or whether it was in fact motivated by an attempt to discredit the most widespread contraceptive method. If doctors were battling against depopulation while at the same time seeking to retain their influence over the domain of contraception, then they may have viewed coitus interruptus as a method that caused great demographic damage while also, by its very nature, lying beyond their influence.

I will now explore how medical discourse in the interwar period approached the issue of who should use contraception and under what circumstances. Doctors were relatively united in their support for the use of contraception in cases in which pregnancy would cause substantial health risks for the woman or could result in damage to the fetus or the birth of a child with a hereditary disease or disorder. In such cases, most doctors agreed, as in the case of abortions: the life of the mother took priority over the potential life of a child. The use of contraception was also viewed as appropriate on eugenic grounds if a child was likely to be born with a mental or physical handicap, generally for hereditary reasons. From a eugenic point of view, however, contraception was an ambivalent matter. Its uncontrolled spread could mean a sharp decline in birth rates and thus have a dysgenic effect. However, its appropriate use, especially by individuals seen as unfit for reproduction, could, on the contrary, lead to a reduction in the number of inferior children. Thus, the question of who should use contraception and under what circumstances was crucial. The abovementioned Vladislav Růžička, in his book Péče o zdatnost potomstva (Caring for the fitness of our progeny), notes that “those who artificially prevent pregnancy are acting incorrectly and harming society as a whole. The artificial restriction of fertility damages the nation more severely than hereditary diseases.”49 However, in a different publication, he recommends the use of contraceptive devices for preventing pregnancy even mentioning specific types of contraception.50 Here too, it is evident that support for or rejection of contraception was not primarily rooted in medical considerations, but in the purpose and manner of its use. It was acceptable and desirable to use contraception to limit the reproductive potential of individuals who, in the eyes of members of the medical profession, were medically unfit or inferior (see below).51 By contrast, (many) doctors opposed the use of contraception by people who were considered the most suitable breeders. In such cases, contraception was viewed as an evil which would lead to what was seen as the decline of the human race or the extinction of the nation.52

Doctors also exercised their influence over reproductive issues by defining the types of women who should not use it. However, this process of definition was not rooted exclusively in medical considerations, as might be expected; rather it took a class-based or eugenic approach, and again it, was shaped by the desire to combat the low birthrate and fear of differential fertility. Contraception was viewed as a logical way for women from the lowest echelons of society to prevent the birth of children who would merely place a further economic burden on the family (and who might also have led to hereditary problems in future generations), but contraception was viewed as entirely unsuitable for middle-class women. Doctors not only refused to accept the use of contraception by middle-class women, they also repeatedly denigrated, in their publications, middle-class women who expressed an interest in contraception. For poor women, they argued, a reduction in the number of offspring was understandable and forgivable, but for women from more prosperous backgrounds it was merely a form of selfishness that could not be tolerated. Women were accused of desiring luxury at the expense of fulfilling their parental duties. They were condemned for their alleged vanity, which caused them to fear the impact of pregnancy on their looks; they were criticized for wanting an easy life, which in the worst case scenario would lead to childlessness, a state which was presented (especially in nationalist contexts) as a form of “heresy.” František Lašek,53 for instance, wrote the following:

In our country too, the declining birthrate is becoming a pressing national problem. In our society too, there is a desire for a comfortable life. Out of selfishness, spouses avoid having children, and they view those with several children as unwise and careless, robbing their children of their inheritance, lacking in restraint. We should consider that no political crisis or economic slump—both always merely temporary situations—can threaten our nation as much as inactivity by parents, and especially mothers. Let us learn from the history of now-extinct nations, including those Slavic peoples who are close to us!54

 

The final part of Lašek’s admonition clearly illustrates that this condemnation of women who used contraception despite not suffering from any health issues should again be viewed in the context of a concern for the quality and quantity of the population. Lašek’s statements, which were not unusual at the time, represent a response to the fact that contraception was substantially more common among the middle and upper classes, as well as a reflection of the already mentioned fear of degeneration, which might ensue if the lower classes (whom eugenicists considered inferior) were to have markedly higher birthrates than the middle and upper classes (considered superior). It is also certain that the fear of the declining birthrate was influenced by anxiety over the fact that contraception enabled sexual intercourse to be separated from the act of procreation (conception). In the interwar period, this separation was still considered the beginning of a process of moral decay that would ultimately engulf the nation. In 1932, František Pachner55 wrote a textbook for trainee midwives in which he warned them only to give contraceptives to a woman who is “sick or exhausted by childbearing, or who already has so many children that she could not support another, etc. They [i.e., the midwives] should not give advice which promotes an impure life or wantonness.”56

It is thus evident that doctors based their decisions on distinct categories which they themselves fashioned. They differentiated between women for whom contraceptives could be prescribed and recommended and women for whom it was not only unacceptable to prescribe contraceptives, but whose efforts to prevent pregnancy were viewed as contemptible and immoral. This second category comprised healthy women living under prosperous circumstances, as well as women who had not yet had (what was seen as) enough children. In publications about sexuality and marriage dating from the 1950s and 1960s, we can often observe the argument that young spouses are not yet in a position to afford to have a first child, or that they are not yet sufficiently mature to do so, and as a consequence, they may want to use contraceptives. However, during the interwar period, doctors took no account whatsoever of the possibility that a healthy, married, and childless woman may want to avoid pregnancy; such a situation is simply not mentioned in the interwar literature on sexual health. The view taken by the authors of these publications was that if a childless woman does indeed seek to avoid becoming pregnant, this indicates that she is immoral, and her behavior should be viewed as unhealthy or pathological. Women who deliberately remained childless were held up as an example of one of the worst disasters that could befall a nation and as a demonstration of the extremes to which unlimited access to contraceptives could potentially lead.

Birth Control under the Control of Doctors

During the first half of the twentieth century, a movement promoting contraception emerged, partly reflecting the attempt to offer members of the general public as much access as possible to contraceptives and also arising from the notion that contraception was an effective means of preventing abortions or poverty. If we view the so-called birth control movement57 in a global context, we see that many doctors (some male, though female doctors58 were perhaps even more involved) played an active role and were leading figures in this movement, yet some doctors were also prominent critics of it. In Czechoslovakia as in other countries, doctors (and medical concerns in general) played a key role in the contraceptive movement, not as leading figures in it, but because the (female) activists who led the Czech contraceptive movement defined their efforts with reference to the health benefits of contraception and cited medical authorities in order to emphasize that what they promoted was in no way controversial, unnatural, or amoral.

Unlike several other European countries, Czechoslovakia did not have a mass contraceptive movement in the first half of the 1920s, but the idea of raising public awareness of contraception did have some proponents. The first positive responses to neo-Malthusianism can be traced to the years before World War I, but interest in educating the general public about contraception did not become widespread until the 1930s, when it arose as a reaction to the very high numbers of illegal abortions and the government’s inability to tackle this problem. In 1932, a society named Zdravotní ochrana ženy (Protecting Women’s Health) was established in Brno. It aimed to reduce the number of illegal abortions being performed, and it helped set up Czechoslovakia’s first contraception advice center. Two years later, in 1934, the Svaz pro kontrolu porodů (Birth Control Association) was established in Prague, proclaiming that its activities would involve representatives of political parties, women’s organizations, and churches. According to its statute, Protecting Women’s Health was to be run by medical professionals with the intention of disseminating information about contraception, teaching women how to use contraceptives, and providing funds to help them purchase contraceptives. The association also set up an advice center for this purpose.59

The influence of doctors on reproductive issues is evident from the way in which both these organizations presented their purpose and activities. Although they were both run by women and offered help primarily to women, the emancipatory aspects of their activities were strongly downplayed, and the medical benefits were foregrounded instead. Both organizations emphasized the positive impacts of contraception on health and presented medical expertise as an integral and essential part of their activities. The society Protecting Women’s Health explicitly declared its goal of striving to make contraception part of public health care, incorporating it into medical research and carrying out scientific studies on it. Several documents connected with the establishment of the society have survived (including correspondence between the society’s secretary Karla Popprová Molínková and several representatives of other women’s associations), as have several versions of the documentation submitted by the society in its application to be listed on the official register of public associations. These documents enable us to trace the shift that occurred between the original ideas of the founders and the final version which eventually gained official approval. The medical aspects of the society’s activities play a key role here. Karla Popprová Molínková originally wanted to establish a society to fight for the decriminalization of abortion, but she failed to win sufficient support for this idea, and so she decided instead to set up a society modeled on similar organizations abroad (mainly in Germany) the primary aim of which would be to inform women about the contraceptive options available to them. Popprová Molínková’s main aim was thus to enable women to decide freely in matters of motherhood and sexuality, but probably for strategic reasons (and influenced by criticism from other female activists), the society gradually shifted its declared focus more towards the domain of public health education, the battle against abortions and medically harmful forms of contraception, and improvements in the quality and accessibility of obstetric care. The shift in focus towards medical aspects of birth control is very clear from the society’s statute. One of the first versions of this document stated that the society would seek to achieve its goal by “disseminating knowledge concerning feminine hygiene and sexual life, with a particular emphasis on the importance of self-discipline and moral responsibility.”60 However, the final draft of the statute (the one eventually accepted by the authorities) replaced this wording with the following: “disseminating knowledge about sexual life by means of medically informed lectures, leaflets, brochures and printed materials.”61 Unfortunately, we lack sources that would cast light on the motives underlying this shift, but it can be assumed that the original wording, which emphasized that the society’s activities would not be detrimental to morality (reflecting the founders’ fears that the society would face stiff opposition in clerical circles), was eventually omitted for strategic reasons, to be replaced by an emphasis on public educational activities (whose quality and importance were guaranteed, as they were supervised by medical experts) and health benefits.

The influence of doctors is likewise clearly visible in the case of the second organization, the Birth Control Association. Here, it is evident that doctors attempted to retain a degree of control over the association’s promotion of contraception. The Birth Control Association managed to recruit the renowned gynecologist Antonín Ostrčil as a collaborator. Ostrčil was, in the 1920s and 1930s, the head physician at the Second Gynecological Clinic in Prague’s Podolí district. An advice center was established at the clinic in 1935, an event reported in the press as follows:

The aim of the center is to give basic advice to women on sexual matters from a gynecological perspective: i.e., in cases of irregular awakening of sexual desire, difficulty caused by a lack of sexual harmony in marital relations, infertility, in cases when it is appropriate to prevent pregnancy, or in cases of various illnesses affecting women, whose treatment could prevent large numbers of abortions with a negative impact on health. The advice center will be run by the head physician of the clinic and his assistants. The association will be governed by the principles laid down by Dr. Ostrčil.62

As is evident from this extract, the activities of the Birth Control Association and specifically the advice center set up by it were clearly framed in terms of protecting health. In this case, the “sickness” that needed to be “treated” consisted of abortions and their detrimental effects on health. The last sentence is particularly significant, as it explicitly positions the association as being subordinate to medical authority, represented by Antonín Ostrčil. It is interesting that, although I have only found very scanty information on the Birth Control Association’s activities, there is not even the slightest attempt to present contraception as a tool enabling women to take control over their own reproductive potential or as a way of experiencing female sexuality without the anxiety of unwanted pregnancy.63 Although these motifs were typical of the contraceptive movement that developed especially in Western Europe and the USA in the second half of the twentieth century, embryonic traces of them can be observed in the contraceptive movements of other countries in the prewar era.64 The absence of these motifs in interwar Czechoslovakia is particularly striking when we take into account that the Birth Control Association was chaired by Betty Karpíšková, a Czech social democratic senator who ranked among the most vocal supporters of the decriminalization of abortion in the interwar period and, above all, one of the few public figures who very explicitly emphasized women’s right to decide in matters of motherhood and to be in control of their own bodies.65 It appears that Karpíšková downplayed these aspects in order to increase the association’s chances of success, deciding instead to emphasize only the medical benefits of birth control. This enabled the association to win more widespread support from doctors (support that was essential in order to create the advice center) and also from members of the general public.

Conclusion

In the interwar period, Czechoslovak doctors attempted to play the role of protectors of society by battling against one of the major perceived threats to the nation, the declining birthrate. They considered it important to retain their influence over reproductive matters, and to do so, while also gaining public support, they framed their discussions of depopulation, abortion, and contraception in terms of the concepts of health and sickness. The debate on abortion in Czechoslovakia, which laid the foundations for the debate on contraception and the emergence of the contraceptive movement, focused mainly on socioeconomic issues, yet it was doctors who played the most influential role in this debate. Arguing from a position of professional authority, they rejected all attempts to expand the range of circumstances under which abortions could be legally permitted, mainly by stating that abortion always represented a risk to health. In discussions on methods of contraception, doctors constructed a category of women who under certain circumstances were justified in practicing birth control and they denigrated a different category of women, who they alleged should not use contraception under any circumstances in order to avoid population decline. The medical perspective was also incorporated into the social movement that promoted contraception. The original effort of emancipating women and giving them the opportunity to make decisions about their own bodies gave way (in the interest of greater conformity and support) to an effort to control women’s reproductive potential and steer it in a direction that was considered exclusively correct by (primarily male) doctors.

Archival Sources

Moravský zemský archiv (Moravian Provincial Archive), Fonds Zemský úřad Brno, box 2936, reference no. 44268.

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