Received Sep 21; Accepted Nov This article has been cited by other articles in PMC. Abstract The primary care physician has a vital role in documenting and preventing sexual abuse among the mentally retarded populations in our community.
Since the current national trend is to integrate citizens with mental retardation into the community away from institutionalized care, it is essential that all physicians have a basic understanding of the unique medical and legal ramifications of their clinical diagnoses. As the legal arena is currently revising laws concerning rights of sexual consent among the mentally retarded, it is essential that determinations of mental competency follow national standards in order to delineate clearly any instance of sexual abuse.
Clinical documentation of sexual abuse and sexually transmitted disease is an important part of a routine examination since many such individuals are indeed sexually active. Legal codes adjudicating sexual abuse cases of the mentally retarded often offer scant protection and vague terminology.
Thus, medical documentation and physician competency rulings form a solid foundation for future work toward legal recourse for the abused. Mentally retarded individuals in the United States are increasingly integrated into the community away from institutionalized care. Because primary care physicians are uniquely positioned in our society to identify and to prevent sexual abuse among these individuals, these health professionals must understand the possible medical and legal consequences of their clinical diagnoses in this population.
In addition, medical perspectives on pertinent aspects of sexual development of mentally retarded individuals and profiles of the typical perpetrators of sexual abuse are provided as a reference for the practicing physician.
Profile of Individuals With Mental Retardation Individuals with mental retardation fall within a spectrum of abilities, characteristics, and personal attributes, as is seen in any general population. However, mentally retarded individuals have developmental delays in learning, processing information, and independently caring for themselves. Such individuals show marked delays in adaptation to a changing environment.
This article uses the standard terms mentally retarded individual or the mentally retarded, both of which are in accordance with the terminology used by both the American Medical Association AMA and the American Association on Mental Retardation AAMR , a strong advocacy group for this population. The reader should note that the term developmentally disabled denotes a broader category that encompasses those with mental retardation, cerebral palsy, epilepsy, autism, or other neurologic conditions closely related to mental retardation.
Medical Classification of Mental Retardation: Open in a separate window First, an individual's intelligence level is usually determined as an intelligence quotient IQ by a licensed examiner using 1 of 4 standard examinations. The Stanford-Binet Scale was the first formal IQ test developed in and has historically been used to assess those aged 2 to 18 years.
Today, it is employed for children below the age of 6, the cognitively impaired, or the extremely gifted.
The Wechsler Preschool and Primary Scale of Intelligence is the most recent modification and is used to assess children 4 to 6 years of age. Average IQ score is , with a normal IQ range in the population varying from 70 to The AMA and APA use the deviation from the means method, and an individual's IQ must be at least 2 standard deviations below the mean to be classified as mental retardation. Even today, the standard method used by states to estimate its mentally retarded population is simply to take 2.
The mental age method can also be used to quantify IQ. Mental age MA is used to describe a person's intellectual level in terms of what would be expected at a certain chronological age CA in a nonretarded individual. As with any standardized test, differences in culture, environment, and language may bias results. Furthermore, intelligence level tests are only part of the diagnosis; sole reliance on IQ or mental age is an inadequate classification of mental retardation.
Unlike the IQ test, which is given in one setting, this evaluation may require several observations and several examiners to compile a composite of the individual's functioning. Open in a separate window Third, since mental retardation is defined as a disruption of a child's developmental process, onset must occur before the age of full mental development, i. Thus, a biological ceiling is placed on the person's ultimate level of achievement.
Four Categories of Mental Retardation Based on the aforementioned standards set forth by the APA, mental retardation is classified into 4 categories: Open in a separate window Mild mental retardation is the most common category and is typified by an IQ of 50—55 to As such, these individuals are usually capable of maintaining a steady job and living in the community.
These individuals are capable of minimal daily functions and are very dependent on a structured and supervised setting. The highest educational level achieved is below the 1st grade, and the group is considered not educable.
This new classification includes 4 levels of support: The physician should be alert to any signs often associated with mental retardation, including hypotonia, hepatosplenomegaly, coarse facial features, abnormal urinary odor, a large tongue, an overly large or small head, delays in sitting or walking, or a delay in pincer grasp, among others.
Yet, because of technological advances that sustain infants with very low birth weight, the prevalence of mental retardation is considered to be constant. It is now recognized that sexual interests and desires of the mild and moderately retarded vary in intensity just like those in the nonretarded population. Thus, ideas of proper sexual conduct are shaped by unreliable influences from the media, peer groups, caretakers with impure motives, or other perpetrators of sexual abuse.
The mentally retarded show a lower rate of offspring production than the nonretarded, yet the majority of mentally retarded individuals are potentially fertile with margins for individual variation. The physician is encouraged to fulfill an advocate's role by broaching the issue of sexual activity with the patient and directing the patient and caregiver toward community resources and support groups to address these issues. Mental Retardation Versus Mental Illness Mental illness is separate from but can coincide with mental retardation.
There is an approximately 2-fold increase in psychopathology among mentally retarded persons. Physicians should be aware that many such individuals may be taking psychoactive medications. It is estimated that these individuals are victimized at 4 to 10 times the rate of the general population. There are several reasons why mentally retarded individuals are especially prone to sexual abuse, the most significant of which is the ingrained reliance on the caregiver authority figure. Such abuse is often extensive and ongoing.
A thorough examination may reveal bruising or infection in the genital area. Thus, it is crucial to document and report any irregularities as early as possible since such sexual abuse is often part of a wider pattern that may also affect other mentally retarded individuals.
The informed aspect includes understanding information as to the nature of the procedure, the risks and benefits of the procedure, and alternative courses of action. The consent aspect includes the voluntary and autonomous nature of the patient's decision. There are 4 recognized exceptions to the doctrine of informed consent: States vary for ages of consent to birth control and abortion.
As Coulehan and Block 27 emphasize repeatedly, informed consent is a process of informational internalization and not just a scribbled patient signature on a piece of paper. Even in the court of law, such a signed document may serve as evidence of informed medical consent but still can be inadequate by itself to prove full consent.
Such consent is contextual in that the setting of questions and answers is most pertinent to the quality of the patient's understanding and agreement. By contrast, the concept of competency belongs to the legal realm.
Competency is the individual's ability to make rational, informed decisions concerning oneself or one's property. A competent individual is able to give informed consent. For example, a patient in a state of coma, unconsciousness, or severe dementia is generally deemed to be incompetent to make medical decisions.
A mentally retarded individual, however, may demonstrate adequate processing skills to be able to make rational decisions regarding sexual activity and thus qualify as competent for such an activity. Thus, it must be emphasized that competence is a legal concept and is not a medical concept. Also, competency is not absolute for all actions; for example, an individual may be assessed as competent for daily living tasks but deemed incompetent for consensual sex.
In helping to determine legal competency, a physician or psychologist generally asks a series of questions or utilizes one of several competency assessment tests to probe the individual's various neurologic, psychological, intellectual, and physical capacities to make an informed decision.
To date, no one test has emerged as providing superior criteria with which to determine the competency of a mentally retarded individual for sexual activity. Because a standard assessment test is neither devised nor universally accepted, the question of decisional competency is currently resolved by analyzing the various components of mental competency.
By nature of the ongoing relationship with the patient, the primary care physician is arguably better positioned than the psychiatrist or psychologist specialist to assess mental competency of the mentally retarded individual. Farnsworth, in a article, 21 set up a valuable algorithm for use in the primary care setting.
The primary care physician is able to assess competency by assessing the 3 main aspects as follows: If there are serious deficits in understanding these 3 main criteria, then the primary physician is fully qualified to prepare the proper documents for the court, including relevant descriptions of the patient and opinions from family members, occupational therapists, psychologists, and other observers. LEGAL ANALYSIS Laws protecting the mentally retarded individual across the nation are consistently characterized by both medical and legal scholars alike as vague, inconsistent, and inadequate in their protection of vulnerable individuals from sexual abuse.
The following few paragraphs will discuss current laws on sexual abuse and will define the legal terminology employed by such statues and codes. Finally, medicine's role in the courtroom will be elucidated with recommendations to the primary care physician on how to play an advocate's role in the clinical setting. Cases of sexual assault are arbitrated differently according to individual state laws and statutes; however, there are 3 main themes that may prove helpful for the physician.
First, states often have statutes for the mentally retarded citizen separate from the general sex offense statutes. Such a separation was originally intended to protect the mentally retarded citizen but in practice has proven to isolate the victim, invoke stereotypes, and impede prosecution of sexual abuse cases. State court guidelines have evolved not from a comprehensive, well-designed plan but from a series of court decision precedents; thus, comprehensive legal protection for the mentally retarded individual is nearly nonexistent.
Her approach would use modern biological knowledge of the developmentally delayed as a basis for consent determination according to the particular context of alleged abuse. Yet, despite the acknowledged difficulties in writing adequate sexual abuse case law, state courts must work with some kind of standard. Third, 6 major tests are used as such a standard to assess the legal capacity of the mentally retarded individual to consent to sexual conduct.
This test necessitates understanding the sexual nature of any sexual conduct and the voluntary aspect of such activity. In sharp contrast to the medical informed consent doctrine, there is no obligation to understand the nature and consequences of such sexual activity, nor is there any obligation to comprehend the morality of the act.
This test is remarkably similar to the medical informed consent doctrine in which the patient must understand both the nature and consequences of a procedure; this test also parallels the medical consent doctrine in that the individual must understand the risks of behavior, including negative outcomes.
This test necessitates a moral understanding of the sexual activity in addition to understanding the nature and consequences of sexual conduct.
Defining Legal Consent Legal consent, like medical informed consent, is greatly influenced by the context of the incident in question. However, in contrast to the doctrine of informed consent, legal consent to sexual activity is by far a more subjective and elusive concept with greater variance from state to state.
As was established, states will greatly vary in their definitions of legal consent with respect to the mentally retarded citizen; however, Stavis and Walker-Hirsch, 1 under the auspices of the AAMR, propose 3 helpful standards of legal consent that are upheld by most advocacy groups as ideal.
Their 23 dimensions can be summarized in 3: Defining Competency Versus Capacity As discussed earlier, competency is a legal concept, but primary care physicians are both able and uniquely positioned to submit opinions for the court's final determination. Competency or incompetency is determined as the situation arises. While incompetency denotes a legal inability to make rational, informed decisions, incapacity is a more expansive legal term that denotes ineligibility and inability regarding basic life decisions.
Although, predictably, state laws governing the finding of incompetency and incapacity are both vague and varied, generally there are provisions to establish a guardianship or conservatorship in the case of a ruling of incompetence.
These roles lie predominately in the areas of IQ, opinions of competency, and sexual history documentation. The IQ of the alleged victim has historically formed the cornerstone of presentations by both the prosecution and the defense. The numerical IQ is used in the courtroom as a key instrument to either establish or disprove competency and the independent social and sexual functioning of the mentally retarded individual in question.
Because IQ is such a powerful psychological assessment, it is crucial that the medical professional pay special attention to establish its accuracy. Further, because of the aforementioned shortcomings of any IQ testing, it is crucial that any strengths and weaknesses outside of the test be documented adequately.