Sexual Abuse in Institutions of Learning Disabled
Literature review that critically analyses the sexual abuse of people with learning disabilities in institutions
There are a great many facets to the problem of sexual abuse of people with learning disabilities in institutions. The wide variety of learning disabilities, the wide scope for different types of sexual abuse and indeed the huge variety in the institutions themselves, means that there is not any unified standpoint or all-encompassing view that can be taken on the subject. (Ryan J et al 1987). This review will therefore consider each of these aspects in turn together with the literature associated with them and then attempt to draw conclusions from a critical evaluation of each
The term learning disability is applied to cover a wide range of different clinical entities. Differing impairments due to differing aetiologies are typically “lumped together “ under this one term. In the context of this review, differentiation of the various types of learning disability is largely irrelevant and the only discriminating factor that may be relevant is the degree of disability or impairment. For that reason alone we shall consider all causes of learning disability and the conclusions reached will therefore largely be generalisations in the area.
Approximately 2% of the UK population are currently classified as having a learning disability and this proportion has been slowly rising over time. In their comprehensive review of the subject, Xenitidis suggests that the reasons for this growth are manifold and complex. (Xenitidis K et al 2000). Part of the reasons given are that the definitions and criteria for the diagnosis of a learning disability are progressively changing as our knowledge of the area expands together with the fact that other relevant factors are changing such as the socio-economic conditions together with the fact that pre-term neonates who would previously been expected to die are now helped to survive but with an increased risk of cognitive impairment and learning disability (Aspray TJ et al. 1999).
The McGrother study suggests that over a 35yr period from 1960 the prevalence of learning disability has increased at an average rate of 1.2% per year (McGrother C et al. 2001).
One of the difficulties encountered in the context of sexual abuse is the problems that there are in discovering it. The typical person with a learning disability may have differing perceptions of “right and wrong” and therefore may not be in a position to make a judgement about what is happening. Other factors are that they have a greater difficulty in accessing professional help. (Wilson D et al 1999).Clearly this is less of a problem if we consider the group who are in institutions rather then those who live in the community, but against this is the argument that those in institutions generally tend to be those with the greatest disability and therefore would intuitively be less able to draw attention to a potential problem. (Patja K. 2000)
The literature in this area is not particularly extensive but there are a few high quality papers that stand out. The first is by Sequeira (Sequeira H et al 2003) which was a case controlled study (a rare construction in this particular area) which set out to consider any correlation between sexual abuse, mental health and behavioural problems in people with learning disabilities. The authors suggest that this is the first study to seek such a connection. They matched a surprisingly large entry cohort of 54 adults with learning disability in a residential setting who had suffered from sexual abuse with a similar cohort who had not been abused. The actual study was both carefully constructed and meticulously carried out. In broad terms the findings of the study were that there was a statistically significant correlation between sexual abuse and mental illness and behavioural problems together with symptoms of post-traumatic stress.
Reassuringly, the authors found that the reactions to abuse were essentially the same as in the general population which suggests that when recognised, the symptoms were evident to observers, but equally this implies that a significant amount of abuse is undetected. (Thompson D et al 1997).
With the group with learning disabilities, the authors concluded that in addition, the study group tended to exhibit stereotypical behaviour patterns and that there was a positive correlation between the degree of abuse and the severity of the symptoms reported. We can confidently conclude therefore that there is a positive association between sexual abuse and both psychiatric and behavioural abnormalities in people who have learning disabilities.
How does the design and architecture of institutions foster abuse?
It has to be observed that an extensive literature search reveals no specific studies on the issues of institution structure and opportunities for abuse. There are a number of papers that refer tangentially to the issue however, and we shall assimilate the points raised in them. Brown, (1999) and Manthorpe (et al, 1999), both observe that institutions, both large and small, are not specifically immune from sexual abuse of their residents. They point to working practices that allow professionals a degree of privacy when dealing with residents in vulnerable situations. (Burke K 1999).
It would be unlikely that anyone would disturb a nurse giving a patient a bath or a doctor conducting an interview or examination of a patient. In this respect, it is not the actual architecture of the institution, it is the structuring of the working practice that fosters the possibility of abuse in this area. (Churchill J 1998).
Some institutions have mixed sex dormitories and areas which can be difficult for nursing staff to monitor. Inter-resident abuse can therefore take place in areas which may be less easy to detect than the open plan structure of many wards in general hospitals (Brown H et al 1997)
Who are the perpetrators of abuse against people with learning disabilities?
This is clearly a difficult area in which to be dogmatic, as one can cite evidence from various enquiries which have examined the issue and have implicated virtually every category of professional from medical staff, (COI 1969), through nurses (COI 1971), to care assistants and sub-contracted employees (DOH 2000). Equally, to be balanced, one has to also examine the recent spate of prosecutions form residential care home workers that have been overturned in the appeal court where allegations of abuse have been found to be vindictive or fraudulent. (also COI 1978)
What impact does power imbalance between carer and service user have over occurrence of abuse?
Abuse, almost by definition, implies an abuse of power.(Northway R 1998).There is automatically an imbalance between those with learning disabilities and those in the general population as, by the very nature of their disability, the majority of those with a learning disability are dependent on other carers for their own protection and safety. (Pillemer K et al. 1993).This power imbalance is taken to a greater extreme when those (healthcare professionals) who are employed to care for their patients, and thereby are generally invested with a degree of trust give instructions to those who are more vulnerable. As Rogers points out, (Rogers AC 1997) the moment a nurse puts on a uniform or the doctor a white coat, they are invested with an automatic degree of authority and respect by the general population and possibly all the more so by those with learning disability, who may well have learned to be more deferential or respectful because these healthcare professionals are effectively the gatekeepers to their own security and well-being. (Sines D 1995)
What can be done to reduce abuse in institutions?
It is clearly important to be able to restore confidence in the residential settings for the care of those with learning disabilities. One of the prime mechanisms of reduction is to place professional emphasis on detection of abuse together with implementation of management procedures that will minimise the potential for abuse. The recent Government White Paper “No Secrets” (DOH 2000) has gone a long way into implementing such measures, and this, together with provincial measures in other parts of the UK (NAW 2000), presents guidelines which will help to prevent sexual abuse and also facilitate the investigation of such abuse when it is alleged.
Professional bodies have publicly proclaimed a policy of Zero tolerance in this area and have encouraged the philosophy of “whistle blowing” (NMC 2002 a) it should be noted however, that a study commissioned by the same group, The Nursing and Midwifery council (NMC 2000 b) suggested that despite the guidance and directives given there is clear evidence that nurses, in particular, do not have sufficient knowledge or have received sufficient training in the area of prevention of sexual abuse to effect the recommendations in the Government White Papers.
References
Aspray TJ, Francis RM, Tyrer SP, and Quilliam SJ 1999 Patients with learning disability in the community BMJ, Feb 1999; 318: 476 – 477
Brown H & Stein J 1997. Sexual abuse perpetrated by men with intellectual disabilities: a comparative study. Journal of Intellectual Disability Research 41 (3) 215-224.
Brown H 1999, Abuse of people with learning disabilities. In: N Stanley J Manthorpe &r B Penhale (Eds) Institutional Abuse: Perspectives Across the Life Coarse. London: Routledge. 1999
Burke K 1999, Nurses told to avoid close relationships with their patients. Nursing Standard 13 (49) 4.
Churchill J 1998, It doesn’t happen here! In: T Thompson & P Mathias (Eds) London: Sage/Open University Press. 1998
COI 1969, Committee of Inquiry (1969) Report of the Committee of Inquiry into Allegations of Ill-treatment of Patients and Other Irregularities at the Ely Hospital, Cardiff. Cmd 3975. London: HMSO.
COI 1971, Committee of Inquiry into Farleigh Hospital (1971) Report of the Committee of Inquiry into Farleigh Hospital. London: HMSO. 1971,
COI 1978, Committee of Inquiry into Normansfield Hospital (1978) Report of the Committee of Inquiry into Normansfield Hospital. Cmd 7357. London: HMSO.1978
DOH 2000, Department of Health (2000), No Secrets: Guidance on Developing and Implementing Mula-agency Policies and Procedures to Protect Vulnerable Adults from Abuse. London: The Stationery Office. 2000
Manthorpe J & Stanley N 1999, Shifting the focus: from ‘bad apples’ to users’ rights. In: N Stanley J Manthorpe &r B Penhale (Eds) Institutional Abuse: Perspectives Across the Life Course. London: Routledge 1999
McGrother C, Thorp C, Taub N, Machado O. 2001, Prevalence, disability and need in adults with severe learning disability. Tiz Learn Dis Rev 2001;6: 4-13
NAW 2000, National Assembly for Wales (2000) In Safe Hands: Protection of Vulnerable Adults in Wales. Cardiff: Social Services Inspectorate for Wales.
NMC (2002 a), Code of Professional Conduct. London: Nursing and Midwifery Council.
NMC (2002 b), Practitioner-Client Relationships and the Prevention of Abuse. London: Nursing and Midwifery Council.
Northway R 1998, Oppression in the Lives of People with Learning Difficulties: A Participatory Study. PhD Thesis. Bristol: University of Bristol.
Patja K. 2000, Life expectancy of people with intellectual disability: a 35-year follow-up study. J Intellect Disabil Res 2000;44: 590-9.
Pillemer K & Hudson B 1993, A model abuse prevention programme for nursing assistants. Gerentologist 33 (1) 128-131.
Rogers AC 1997, Vulnerability health and healthcare. Journal of Advanced Nursing 26 65-72.
Ryan J & Thomas F 1987, The Politics of Mental Handicap. London: Free Association Books.
Sequeira H, Howlin P, Hollins S 2003, Psychological disturbance associated with sexual abuse in people with learning disabilities, The British Journal of Psychiatry (2003) 183: 451-456
Sines D 1995, Impaired autonomy: the challenge of caring. Journal of Clinical Nursing 4 (2) 109-115.
Thompson D, Clare I & Brown H 1997, Not such an ordinary relationship: the role of women support staff in relation to men with learning disabilities who have difficult sexual behaviour. Disability and Society 12 (4) 573-592.
Wilson D, Haire A. 1999, Health care screening for people with mental handicap living in the community., BMJ 1999;301: 1379-81
Xenitidis K. Thornicroft G. Leese M. Slade M. Fotiadou M. Philp H. Sayer J. Harris E. McGee D. Murphy DG. 2000, Reliability and validity of the CANDID-a needs assessment instrument for adults with learning disabilities and mental health problems. British Journal of Psychiatry. 176:473-8, 2000 May
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