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CHAPTER 13:SEXUALITY AND PEOPLE WITH LEARNING DISABILITIES

MEERA ROY

Sexuality relates to how people express themselves as men and women. This is culturally defined and influenced by family, peers, religion, the law, customs , knowledge and economics. Sexual maturity is a biological process which happens to almost everyone, including people with a learning disability (the exceptions include people with syndromes affecting sexual maturation). Heshusius (1987) reviewed literature on perceptions of sexuality by people with learning disabilities and found that “ at least for most part, sex is desirable ,an essential part of life pleasurable and adding warmth and excitement to living - not unlike the meaning it carries for most people”. In this chapter, we will examine how society has responded to people with learning disabilities expressing their sexuality and the particular issues which face them in the areas of sex education, abuse, contraception and in being parents.

HISTORICAL OVERVIEW

Expression of sexuality by people with a learning disability has caused unease in the society in general and carers in particular from very early times. Until recent years, the response has been to lock them away in institutions where the practices allowed little scope for appropriate sexual behaviour. Eugenics is the term applied to theories and practices ostensibly designed to improve human condition from the point of view of genetics. But identification of desirable human traits is a subjective matter. References to eugenic ideals appear in the Old Testament and Plato’s Republic idealises a society in which there is a constant selection for the improvement of human stock.

In the United Kingdom, the Eugenic Education Society was set up in the early part of the 20^th century, drawing its membership from the middle classes and it was most concerned by the growing problem presented by the “feeble minded”. In response to the growing pressure, a Royal Commission was set up under the Chairmanship of the Earl of Radnor in 1904, which deliberated for 4 years. The Commission came to the conclusion that heredity was an important factor in “mental deficiency”, the “defectives” were often highly prolific and that other social problems such as delinquency and alcoholism were aggravated by the fact that so many “defectives” were allowed complete freedom of action in the community. But they were not willing to consider sterilisation as an option and insisted that the main criterion for certification should be the protection and happiness of the “defective” than the purification of the race. In 1910, the members of the Eugenic Society and the National Association for the care of the Feeble-Minded lobbied the candidates for the General Election, asking them to support prevention of parenthood for the feeble minded. But the Mental Deficiency Act of 1913 did not deal with the issue of sterilisation.

A joint committee of the Board of Education and the Board of Control under the chairmanship of A.H. Wood in 1924 was asked to determine how many “feeble minded” people there were and how to deal with them. Their conclusion was that the real criterion of “mental deficiency” was social inefficiency and not educational subnormality and laid down principles of care. They recommended segregation and sterilisation for the elimination of those with “primary amentia”. A Department of Health Committee chaired by L.G. Brock in 1934 recommended sterilisation for the “mentally defectives” with third party consent, but this was not acted upon.

In the United States, The American Eugenics Society was founded in 1926 by men who believed that the white race was superior to other races and that the upper classes had superior hereditary qualities that justified their being the ruling class. Sterilisation and segregation of “defective” people was thought to be the best way to improve society. By 1931, sterilisation laws had been enacted by 27 states in the U.S. and by 1935, similar laws had been passed in Denmark, Switzerland, Germany , Norway and Sweden. In most cases the purpose was clearly eugenic, though some laws tacitly permitted sterilisation for social than genetic reasons.

Following the atrocities in Hitler’s Germany during the Second World War, the Eugenic movement fell into disgrace. In 1942 in Skinner v Oklahoma the US Supreme Court ruling was “ the right to procreate is a basic constitutional one”, demonstrating a diametrically opposite view from that expressed by Oliver Wendell Holmes 1927 in the same court, in Buck v Bell which was that “ three generations of imbeciles are enough”.

Sterilisation and people with learning disabilities

Once the Eugenic argument is put aside, there still remains family or carer issues which impinge on sexual rights of this group of people. Adults with learning disability are often looked upon as children and therefore asexual. Alternatively, they may be regarded as people with an excessive sexual drive and with poor personal control. Parents give a variety of reasons for seeking to have their children with learning disabilities sterilised. Some feel that irresponsible behaviour on the part of their daughters will lead to their sexual exploitation. Others dread the possible emotional and economic burden of bringing up a child resulting from such a sexual encounter. There is a common belief that their daughter’s disability would be transmitted to the next generation. Some parents favour sterilisation, believing that it would result in a lowering of sexual drive. Others do so because they fear the social stigma which would result from their daughter becoming pregnant and the possibility of this being attributed to insufficient control and supervision on their part. Most requests for sterilisation come not from women with learning disabilities but from their parents, who feel that they have a right to be free from worry about their offspring beyond a certain age. Parents sometimes also cite their grandchildren’s right to be born without disabilities.

In the recent years, such cases have come into public domain leading to the clarification of the legal situation in England and Wales. In the case of minors, such an operation should only be carried out with the leave of the High Court Judge obtained in Ward ship proceedings. In case of adults over the age of 18 years who cannot consent , the operation should be in their best interests and should be in accordance with the responsible body of medical opinion. The doctor performing the operation must consult all the relevant professionals and family members and should apply to the Court for a Declaration that under facts of the case, the operation would be lawful (Whitfield, 1989 ).

In Scotland, the law is different as childhood is divided into two following the Roman Law classification of persons. There are pupils protected and controlled by tutors (normally the parents), who have full control (subject to the Welfare principle), over the pupil’s property and person and there are minors (between the ages of 12 or 14 and 18), protected by curators who only have control over the child’s property. A tutor has the right to decide on medical treatment for the child and a tutor dative can be appointed by the Sessions Court to consent to medical treatment for an adult as long as it is in his or her best interests ( McK. Norrie, 1989 ).

Today, in the United States, there appear to be three different approaches to sterilisation in the different states. In some states, the operation cannot be performed on a person who cannot consent. In the second group, the Court can evaluate cases for sterilisation and authorise the procedure if it is considered to be in their best interests. The third approach is to leave the decision to members of the family and their physician with out resort to the courts (Annas, 1981). In Canada, the Supreme Court concluded that “non-therapeutic” sterilisations cannot be authorised by a Court( McK. Norrie, 1989). In Australia, in the state of Victoria, all sterilisation operations have to be referred to the Guardianship tribunal (Carney and Singer, 1986).

SEX EDUCATION

Sterilisation of people with a learning disability may be seen as an extreme reaction to their sexuality. In the last few years , it has been viewed more positively and there has been an increasing public awareness about the right of people with learning disabilities to be treated like others with out such disabilities, by the pioneering work by Wolfensberger in the context of normalisation or social role valorisation. In 1979, the United Nations adopted a Declaration of the Rights of the Mentally Handicapped, which states that “the mentally retarded have the same basic rights as other citizens of the same country and same age”.

Craft (1987) believed that people with learning disabilities have six main rights with regard to their sexuality:

1. The right to grow up and to be treated with the respect and dignity accorded to adults. This is often compromised due to their need for some level of support. All too often the support given has the effect of encouraging dependence.

2. The right to know. To have access to as much information about themselves and their bodies and those of other people, their emotions, appropriate social behaviour, etc. as they can assimilate.

3. The right to be sexual and make and break relationships.

4. The right not to be at the mercy of the individual sexual attitudes of different care givers.

5. The right not to be sexually abused.

6. The right to a humane and dignified environment.

In the last decade, there have been improvements in the provision of sex education for the general population and people with learning disabilities. The attitudes of staff in residential settings have become more progressive towards an acceptance of a socio-sexual life for the people in their care ( Heshusius, 1987 ). Those who receive sex education appear to benefit substantially in terms of knowledge, growth and self confidence( Robinson, 1987). With out this, they will not be able to develop meaningful relationships .

As the majority of people with learning disabilities live with parents or paid carers, such carers have an important role to play in the development and expression of sexuality. In planning sex education, it is important that parents and carers are consulted at an early stage. Training staff to deal appropriately with sexuality is essential to prevent traditional repressive reactions. Training has to be at least on two levels. All staff need awareness training - awareness that individuals with a learning disability have needs and rights in relation to their sexuality. They also need information on a range of issues such as local services, availability of educational materials, pregnancy etc. At a second level, a small number of staff may want to obtain further training to work as teachers and counsellors themselves. Various organisations e.g. British Institute of Learning Disabilities , the Association to Aid the Personal and Sexual Relationships of People with Learning Disabilities and the Education and Training Department of the Family Planning Association run such courses(Craft and Brown,1994). There are training packs, e.g. Not a Child Anymore by the Brook Advisory Service which can be used to give people with learning disabilities, sex education.

An important prerequisite for effective sex education is an awareness and understanding of one’s own attitudes, beliefs and practices regarding sexuality and towards people with learning disabilities. Those providing the service must be sensitive to the needs of minority groups such as asians and african carribean people and guard against negative stereotypes such as black people and those with learning disabilities have strong sexual desires (Baxter, 1994).

PEOPLE WITH LEARNING DISABILITIES AS PARENTS

In 1942 the US Supreme Court stated that the right to procreate was a basic constitutional right. Sterilisation would forever deprive a person of this right, which is fundamental to the existence and survival of the human race. The Law Lords in 1987 considered that the presence of physical and mental disability in a girl rendered her incapable of ever exercising that right or enjoying that privilege.

Andron and Tymchuk reviewed a large body of literature on people with learning disabilities functioning as parents. The main drawbacks of the studies were that (1) they concerned deinstitutionalised people necessitating caution in generalising the findings to people raised and living in the community, (2) the parents studied were not representative of the general population as they had been referred by the courts and (3) there was a general lack of sophistication with a lack of comparability of methodology. There appeared to be no clear evidence to suggest that people with learning disabilities predominantly had children with learning disabilities. However, as many of these people lived in impoverished environments, it is difficult to determine the effects of poverty as opposed to being brought up by parents with disabilities. Gillberg (1983) however found that women with learning disabilities had more children than the general population and that they had more children with learning disabilities. Women with learning disabilities who do well as mothers have the following traits: Adequate reading and comprehension abilities to use traditional sources of information such as parenting manuals, IQ above 60, no concomitant emotional disturbance, no concomitant medical disorders, low stress, adequate self concept and adequate motivation. Good outcome is also associated with the following environmental factors: there being only one child in the house, having a younger child, having a child without medical or other problems, having a partner without an emotional disorder, criminal behaviour or behaviour problems including abuse of spouse, having sufficient supports (social, health, financial, vocational, psychological and legal) not having been institutionalised, having had own appropriate role models during own upbringing, having adequately trained professionals, availability and appropriateness of materials used in training, continuity of agency involvement and having a single agency providing multiple services and or co-ordination (Tymchuk 1990).

Normal intelligence does not guarantee good parenting skills. Conversely, presence of learning disabilities does not preclude the ability to be a good parent. If a person with learning disabilities is to be a parent , he or she should be assessed to find out their strengths and areas where they are likely to need help. Under the current legislation , the child’s needs have to be paramount. Early assessment and planned intervention is essential to ensure that there is as little disruption as possible for the child and the parents with learning disability. Parenting skills can be assessed in family centres where people with learning disabilities can also receive training in child care. Psychologists and psychiatrists working in the field of learning disability may be called upon to give expert opinion on cognitive abilities and presence of psychiatric disorders which may affect the ability to parent. There should be close liaison between community learning disability teams supporting the person with learning disabilities, child care teams, family centre staff , partners, the person with learning disabilities and any involved family member. . If the decision is that the individual can cope, the next step is to put together a comprehensive package to cover the period leading up to delivery and the post natal period. The parent with learning disabilities may need help and support over a long period of time, to help them deal with the child’s developmental stages. However, if it appears that the person is likely to put the child at risk either during the initial assessment or any time later, it will be necessary to implement child care proceedings.

In their book, Parenting Under Pressure, Tim Booth and Wendy Booth (1994)describe their work with parents with learning disabilities. They suggest that much remains to be learned in this field , particularly on achieving a balance between the welfare of the children and the rights of the parents. All too often the balance is tipped against the parents. While children must be protected, it is important that the parents with learning disabilities are not abused by the system. Prosser (1992) defined a number of characteristics of “system abuse” of parents, based on their perceptions of the treatment that they had received at the hands of child protection agencies. These include actions that harm the people that they are supposed to help; snap judgements taken on the basis of inadequate evidence; failing to involve people in decisions affecting them; adding to the problems already facing them; seeing people in isolation from their close relationships; and treating people as ciphers. Booth and Booth suggest a set of guidelines for practitioners working with parents with learning disabilities which are useful to adopt to reduce prejudicial attitudes and misconceptions. It is important that workers in child protection agencies have a good understanding of people with learning disabilities if latter are to have a chance of succeeding as parents. But even practitioners who are sympathetic find themselves trapped by the system into taking actions or decisions which oppress them. This suggests that there may be a need to change the service system itself.

CONTRACEPTIVE OPTIONS

In the main, people with learning disabilities have the same range of contraceptive options as the general population and the choice of a contraceptive depends on the person’s individual circumstances.

Natural family planning methods such having intercourse only in the safe period require motivation knowledge and planning on the part of the users. This is not a fool proof method for most people including those with learning disabilities. Barrier methods (such as condoms) may be suitable for people with mild learning disabilities who are motivated to have good contraception with out having to take tablets. Absence of co-existing personality disorders with poor impulse control and physical disabilities which compromise manual dexterity would increase the success rate of these methods.

Intrauterine devices (IUDs) are highly effective, have no metabolic side effects and only a single act of motivation is required for long term use. Once in situ, they only need to be checked annually. They are often used by women who have borne children, as side effects such as pain during periods and heavy loss occur less often than in nulliparous women. Devices containing progesterone are said to cause less loss during periods. Intra uterine devices are suitable for women with mild learning disabilities who may have problems remembering to take the pill everyday. This is often the reason why ordinary women chose to use IUDs. They may also be suitable for women with severe learning disabilities who are unable to take oral contraceptive pills because of the side effects. However, heavier menstruation may exacerbate any hygiene-related problems and a general anaesthetic may be necessary, both for the insertion and annual checks. In view of the risk of removal by the woman or her partner, shorter threads on the device and more frequent checks may be advisable. The use of IUDs is generally inadvisable in nulliparous women due to the increased risk of pelvic infection and infertility.

Oral contraceptive pill would be the method of choice for women with mild learning disabilities who are motivated to have a safe efficient system of contraception. It can also be used by women with more severe degrees of learning disabilities who are given their medication by their carers. A higher dose of the combined (oestrogen and progestogen) pill may be necessary if the woman is concurrently taking an anticonvulsant which induces liver enzymes. Injectable depot preparations of progesterone may be useful for women with mild learning disabilities for short periods of time if compliance is poor and IUD not appropriate. It may also be useful for women with severe learning disabilities for whom a general anaesthetic may be unsuitable due to other physical problems. Amenorrhoea, which frequently occurs with long term use, may be beneficial. Careful counselling is required to ensure that the woman is able to give informed consent.

Sterilisation (consisting of tubal ligation for women and vasectomy for men) is a safe and permanent method of contraception. Voluntary sterilisation of either partner is the most frequently used method of fertility regulation in the world. Men and women with mild learning disabilities who have completed their families and are able to give informed consent can make use of this option. Women with severe learning disabilities who are unable to consent but are sexually active and unable to use other options such as the pill or IUD because of side effects can also have sterilisation as long as the doctor performing the surgery has followed the guidelines outlined earlier in the chapter. The relatively permanent nature of sterilisation and the issue of informed consent are the main drawbacks.

Consent

Informed consent is an essential prerequisite for any treatment. The various components are:

* it must be voluntary and obtained without misrepresentation or fraud

* the act performed must be consistent with the act for which consent was obtained

* the act must not in itself be illegal

* the person must be given sufficient information regarding the purpose, nature and consequences of the proposed treatment in order to arrive at a reasoned decision regarding whether to accept or reject the treatment

* the person must have the legal capacity (age and mental competence) to give consent

Mental competence is defined as the intellect’s ability to meet a challenge. In people with learning disabilities it can be difficult to ascertain the degree of competence, to know if a reasoned decision has been reached and if it is truly voluntary. When the learning disability is severe there is often a total incapacity to communicate and give consent. In these circumstances third party consent has been obtained in the past, from parents or guardians, and from a court in the case of children. This is acceptable in situations in which the person’s life is at risk, but becomes untenable when the issue is potentially irreversible control of fertility. The current legal status is that parents, guardians or the court can consent on behalf of a person with learning disabilities up to the age of 18 years for treatments excluding those which would interfere with fertility. Beyond this age, no one can give consent on behalf of another. The law regarding sterilisation has been discussed earlier in the chapter.

SEXUAL ABUSE OF PEOPLE WITH LEARNING DISABILITIES

Like other people with disabilities, those with learning disabilities also have been shown to experience greater risk for sexual abuse. Browning and Boatman (1977) found that fourteen percent of incest victims had intellectual disabilities. Elvick et al (1990) physically examined 35 girls and women (ages 13-55) with mental retardation and found thirty seven percent had clear physical evidence of sexual abuse, an additional six percent had known history of sexual assaults and another six percent were found to have sexually transmitted diseases.

People with learning disabilities have an increased vulnerability to abuse because of the dependence on other people for personal care; an imbalance of power between the person being cared for and the carer; difficulties in communication; lack of sexual knowledge and assertiveness; and guilt and shame at being disabled( Sinason, 1993a,b).Turk and Brown(1993) in their study found that the victims were usually women and the perpetrators usually men and that the perpetrator was often known to the victim. Many perpetrators abuse more than one victim.

The victim of abuse may present with changes in personality or behaviour, sexually inappropriate behaviour, withdrawal, sleep disturbance, loss of skills or reduced level of functioning, loss or reduction in speech, self injurious behaviour or symptoms of post traumatic stress disorder. To date , there have been very few successful prosecution against perpetrators. Many cases do not get to Court as the Crown Prosecution Service or the Police consider a person with learning disabilities to be an unreliable witness (Cooke& Sinason,1998).

Children and adults with mental and physical disabilities face particular difficulties when trying to tell of abuse. They are more likely to be disbelieved or even ignored. Their communication problems are exploited by their abuser who is subtly aided by many of the unthinking networks in which they exist. The therapists are often disadvantaged too as they may not have skills in the field of learning disabilities. The communication problem may be further compounded by the emotional trauma of abuse for the person with learning disabilities. Body language may be used to communicate sexual abuse e.g. excessive masturbation or eroticised inappropriate behaviour (Sinason 1994).

Various psychotherapeutic approaches have been modified to treat the victims of abuse. Psychiatric illness precipitated by sexual abuse, e.g. depression , should be treated with appropriate medication. Defects in cognitive functioning may make it difficult to process memories and emotions induced by the abuse, leading to chronic psychological dysfunctioning (Cooke & Sinason, 1998). Professionals working in the field of learning disability should be aware of sexual abuse. It is recommended that health and social service units should have procedures to deal with alleged sexual abuse.

People with learning disabilities as sex offenders

It is commonly agreed that deviant sexual behaviour is similar for disabled and non-disabled offenders ( Sinason, 1993,b). Such offenders can be more violent and more likely to find male victims. They are less likely to reach the courts and therefore less likely to receive treatment. Re-offending is common in sex offenders with learning disabilities (Day, 1993) . He found that majority had committed more than one type of sex offence, 20% had committed both heterosexual and homosexual offences and 50% had offended against children. The offenders had suffered adverse psychosocial factors including parental violence, sexual abuse and multiple family pathology. He differentiated between those who had committed sex offences only as opposed to those in whom the sexual offence was part of a larger context of offending behaviour and suggested that the former were more amenable to treatment.

Various therapeutic interventions such as individual and group therapy have been used with sex offenders with learning disabilities. Sometimes it may be necessary to use antilibidinal agents such as Cypropterone Acetate to reduce the sexual drive.

CONCLUSION

Sexuality of people with a learning disability is clearly a complex area. Cares, statutory agencies and the legal system impact on this area of their lives which is a private one for most others. It is important that any intervention is thought out carefully and implemented sensitively if these people are to feel valued.

REFERENCES

Annas, G. J. (1981) Sterilisation of the mentally retarded: a decision for the Courts. The Hastings Centre Report. Aug.,18-19.

Baxter, C. Sex education in the multiracial society in Craft, A.(ED) Practical issues in Sexuality and Learning Disabilities. Routledge. London.1994.

Booth, T. , Booth, W. ( 1994 ) Parenting Under Pressure: mothers and fathers with learning difficulties. Open University Press, Buckingham.

Browning, D.H. and Boatman, B. (1977) Incest: children at risk. American Journal of Psychiatry, 13, 69-72.

Carney, T. , Singer, P. Medical , income and property matters in Ethical and Legal issues in Guardianship Options for Intellectually Disadvantaged People. Australian Government Publishing Service. Canberra. 1986.

Cooke, L. B. , Sinason, V. (1998) Abuse of people with learning disabilities and other vulnerable adults. Advances in Psychiatric Treatment. Vol.4, 119-125.

Craft, A. , and Brown, H. Personal relationships and sexuality: the staff role, in Craft, A. (ED) Practical issues in Sexuality and Learning Disabilities. Routledge. London. 1994.

Craft, A. Mental Handicap and Sexuality: Issues for individuals with a Mental Handicap, their Parents and Professionals in Craft, A (Ed) Tunbridge Wells, Costello 1987.

Day, K. (1993) Crime and mental retardation: a review. In Clinical Approaches to the Mentally Disordered Offender(eds K. Howells& C. R. Hollin). John Wiley and Sons. Chichester.

Gillberg, C. Geijer-Karlsson, M. Children born to Mentally Retarded mothers, a one to twenty one year follow up study of 41 cases, Psychol. Med. 1983 Vol. 13, 891-894.

Elvik, S.L. Berkowitz, C.D. Nicholas, E. Lipman, J.L. and Inkelis, S.H. (1990) "Sexual abuse in the developmentally disabled: dilemmas in diagnosis". Child Abuse and Neglect 14, 497-502.

Heshusius, L. Research on Perceptions of Sexuality by Persons Labelled Mentally Retarded in Craft, A. (Ed) Mental Handicap and Sexuality: Issues and Perspectives, Tunbridge Wells, Costello 1987.

McK. Norrie, K. (1989) Sterilisation of the Mentally Disabled in the English and Canadian Law. International and Comparative Law Quarterly, Vol38, 387-393.

Prosser, J. (1992) Child Abuse Investigations: The Families’ Perspective. Stansted, Essex, Parents Against Injustice ( PAIN ).

Robinson, S.M. Experiences of Sex Education Programmes for Adults who are Intellectually Handicapped in Craft, A. (Ed) Mental Handicap and Sexuality: Issues and Perspectives, Tunbridge Wells, Costello. 1987.

Sinason, V. Working with sexually abused individuals who have a learning disability in Craft, A. (ED) Practice issues in Sexuality and Learning Disabilities, Routledge, London and New York, 1994.

Sinason, V. (1993,a) Mental Handicap and Human Condition . Free Association Books London.

Sinason, V. (1993,b) The vulnerability of the Handicapped Child and Adult. In Clinical Paediatrics, Child Abuse (eds C.J. Hobbs & J.M.Wynne ) pp.69-87. Balliere Tindall. London.

Sobsey, D. Sexual abuse of individuals with intellectual disability in Craft A. (Ed) Practice issues in Sexuality and Learning Disabilities, Routledge, London and New York, 1994.

Turk,V., Brown,H. (1993) The sexual abuse of adults with learning disabilities: the results of a two year incidence survey. Mental Handicap Research, 6, 193-216.

Tymchuk, A. Yokota, A. and Rahbar, B (1990) "Decision making abilities of mothers with mental retardation". Research in Developmental Disabilities, 11, 97-109.

Whitfield, A. The sterilisation of Mentally impaired Patients. Medical Protection Society Annual Report. 1989, 15.

FURTHER READING

Gunn, M.J. Sex and Law: a brief guide for staff working with people with learning difficulties. London: Family Planning Association.

Jones, K. Mental Health and Social Policy 1945-1959, Routledge and Kegan Paul, 1960.

Mental Handicap and Sexuality: Issues and Perspectives, Craft, A. (Ed), Costello, Tunbridge Wells, 1987.

Practice Issues in Sexuality and Learning Disabilities, Craft, A. (Ed), Routledge, London and New York, 1994.

Roy, M., Corbett, J.A., Newton, J., Roy, A. (1993) Women with a learning disability referred for sterilisation, assessment and follow up. Journal of Obstetrics and Gynaecology, Vol. 13, No. 4, 270-75.

Roy, M., Corbett, J.A., Newton, J., Roy, A. (1993) Referrals of persons with a learning disability for fertility regulation. A regional survey. Journal of Obstetrics and Gynaecology, Vol. 13, No. 5 361-64.

Roy, M., Corbett, J.A., Newton, J., Roy, A. (1993) Assessment of fertility regulations in persons with a learning disability - antecedents. Journal of Obstetrics and Gynaecology, Vol. 13, No. 6, 473-80.

Roy, M., Roy, A. (1988) Sterilisation for girls and women with mental handicap. Some ethical and moral considerations. Mental Handicap Vol. 16, 97-100.