JRSM >
Volume 94, Number 5 >
Pp. 245-246
Specialist Services for People with Learning Disabilities, East London & City Mental Health NHS Trust, 130A Sewardstone Road, London E2 9HN, UK
Correspondence to: Dr Jean O'Hara E-mail: johara{at}doctors.org.uk
People with learning disabilities are vulnerable to sexual exploitation and abuse1. Moreover, when incidents occur, the victims are sometimes perceived to make poor witnesses and the cases do not come to court2. Support and care may demand a multi-agency approach3,4, as illustrated by the following case.
CASE HISTORY
A woman with severe learning disabilities, from an ethnic minority group, was referred to her local community team for people with learning disabilities (CTLD) for specific nursing support around a termination of pregnancy. A disclosure of sexual abuse to her community keyworker also resulted in the involvement of social services, the police, primary care services and specialist health services for people with learning disabilities. In spoken and sign language (Makaton) she consistently identified the alleged perpetrator and communicated her distress. Findings on examination were consistent with a pregnancy of 6 weeks gestation.
Since the allegation involved a family member, social services offered the client the option of moving into a woman's refuge for people with learning disabilities. She accepted despite loss of daily contact with her daughter, who could not be accommodated. This decision provoked hostility from her extended family toward any professional. The CTLD allocated an experienced community nurse to support the client and liaise with other agencies, and a dedicated adult protection worker took the lead in coordinating and chairing multi-agency meetings between health services, social services and the police. A social services care manager was appointed to oversee the client's community care plan, which involved her safe house, day care, transport, funding issues and access to her daughter.
Termination of pregnancy
The client consistently indicated through Makaton singing and her limited
verbal skills that she did not want the pregnancy to continue to term. She
referred to the pregnancy as a ‘bad baby’, and reinforced this by
signing ‘bad’, saying she wanted it ‘taken away’.
Concerns that she was being pressured into accepting a termination of
pregnancy generated extra vigilance to ensure that she understood the
consequences and was determined on this course of action. She constantly
reaffirmed her choice. The process was initially explained by her community
nurse and she then had a routine pretermination counselling session with the
local women's health clinic, rechecked by the consultant gynaecologist. Her
community nurse was present at every session, to help alleviate anxiety for
all parties, to provide continuity of care for the client and to facilitate
communication. The pregnancy was terminated at ten weeks' gestation. The
police, fully involved at every stage, took away swabs, blood samples and
products of conception. Forensic evidence supported the client's
identification of the assailant.
Continuing care
The client's placement at the safe house was not without difficulty. Staff
were concerned about her health needs after the termination; they required
support and reassurance about basic aftercare. The client's family were
concerned that her cultural needs were being ignored, though she had been
offered and had refused special foods and cultural attire. The family
subsequently expressed the belief that her learning disability was too severe
to allow such choices, which had somehow been engineered by the professionals.
However, when the client made a decision which was in keeping with their own
wishes, they insisted she did have the ability to make informed choices. It
was recognized by all that the client needed to maintain regular contact with
her child. This was arranged by social services twice weekly on neutral
territory, though the family sometimes sabotaged arrangements.
Handling by the police
The police handled this case sensitively and took the allegations
seriously. They conducted their interviews through a series of visits to the
safe house, in consultation with clinicians from the CTLD. Two formal
interviews were conducted in a specially designed suite with two-way mirrors
and video-recording, employing Makaton signing, English and the client's
mother-tongue and photographs of people, including the alleged perpetrator.
‘Fuzzy felt’, widely used in interviews with children to represent
people, was considered to be too abstract for this client's level of cognitive
ability.
Early in their enquiries the police also obtained a psychiatric assessment with regard to the client's level of understanding and ability to consent to sexual relationships. This suggested the client was functioning within the severely disabled range (correlating with a mental age under 7 years). The client showed basic knowledge of family roles and social boundaries as well as basic sexual knowledge with regard to sexual touching, intercourse, pregnancy and termination. However, her ability to make informed choices was vulnerable to power imbalances and external pressures. The question was not only could she, but also did she, give informed consent.
COMMENT
This client was able to give reliable and consistent evidence if interviewed in a manner that took into account her cognitive abilities. However, despite all the efforts and the evidence obtained, the case did not reach the courts.
Ability to consent is a complex and multifaceted issue. Assessment of capacity must concern itself with the specific question at hand5, and this client was deemed able to make certain choices with appropriate information and support. Her capacity is clearly vulnerable to external pressures and influences, and her ability to express that choice is undermined by imbalances of power in any given relationship. In the eyes of the law, her learning disability would make her incapable of giving consent.
Women need advocates, and healthcare professionals should provide that advocacy as well as support and care for victims4. Nowhere is this need more evident than in the field of learning disabilities.
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