The Sterilization of Mental Defectives
- Author:
Tredgold, M.D.
No person who possesses a spark of humane feeling-, or who has any concern for the prosperity and happiness of our nation, can be other than impressed with the necessity for preventing- mental deficiency. For it has been demonstrated to the full that mental defectives can never become independent and efficient citizens; that, from an economic standpoint, the lower grades are not only totally unpro- ductive, but that they absorb a vast amount of time and attention from persons who might be more profitably employed; that not a few of them are possessed of habits and propensities which render them no inconsiderable menace to the community; that their offspring are almost invariably of sub-normal intelligence and often enough actually defective; that, in short, mental defectives not only detract very considerably from the happiness and efficiency of the nation, but that they constitute an ever growing financial burden which the country is ill able to bear and for which it gets no return. On all grounds, therefore, whether of happiness and general well-being, of efficiency and prosperity, of Eugenics and progress, even as a plain business proposition, the question of the prevention of mental defect is one of paramount importance.
Some of us have been preaching these facts for many years, and for a long time it almost seemed as if our efforts were in vain so far as the general public were concerned. But recently the seed has shown signs of life. Articles in the public press, discussions, even resolutions, by Boards of Guardians and other bodies have become more and more frequent, and it is plain that at last public feeling is being aroused. Coincident with this it has become generally known that by means of a comparatively trifling operation upon either sex, propagation may be effectually prevented, without otherwise interfering with physiological functions. Very naturally, it has occurred to many people that here lies the remedy, and that we have only to bring- in a law for the compulsory sterilization of all mental defectives to secure the prevention so much desired.
It is not always the seemingly obvious course, however, which is the best one. Many persons having a practical knowledge of mental defectives were by no means convinced that sterilization would produce the results which were claimed for it. It seemed to them that the disadvantages might even outweigh the advantages. Consequently, when the question was brought before the Council of the Central Association for Mental Welfare in June, 1922, it was decided to refer it to the Standing Medical Committee for their opinion. This Committee, which consists of Superintendents of Institutions and Mental Specialists having a wide knowledge of all classes of defectives, considered the matter fully and carefully. They were well aware of the cost of institutional care and of the urgent need for economy; they were even more alive to the necessity for preventing propagation by defectives; nevertheless, while of the opinion that sterilization might be appropriate in certain particular cases, they were unanimous in deciding against it as a general measure to be applied indis- criminately to all defectives. They came to the conclusion that such general adoption would have comparatively little effect in preventing mental deficiency; that it would certainly lead to serious social evils ; and that, as a general policy, some form of segregation was far preferable to sterilization. The Council of the Association were in complete agreement with these views of the Medical Committee and they authorised the publication of a pamphlet dealing with the question.*
The subject has recently been brought somewhat prominently before the general public. Indeed, it may almost be said that a campaign has been launched with the object of bringing about the compulsory sterilization of all mental defectives. This campaign has undoubtedly been undertaken with the best of intentions and with a real desire to benefit the country. Its authors are anxious, and rightly anxious, not only to prevent mental deficiency, but to lessen the expense to the nation consequent on the maintenance of these persons in institutions. Since, however, few of the persons responsible for this campaign have that intimate and practical knowledge of the habits, propensities and limita- tions of defectives which can only be obtained by close association with them over a long term of years, and since the great majority of those having such experience are convinced that sterilization, as a general measure, would not produce the results claimed for it; that it would, in fact, be attended with more harm than good, it seems desirable that the subject should again be referred to. Before sterilization could be put into practice an Act of Parliament would be needed, and an objection which is frequently urged against it is that the passing of such an Act is quite out of the question in the present state of public opinion. I have no doubt that this is so, and that this objection is sound. If a Bill were presented to Parliament to-morrow I think it would certainly be rejected, and that many years of propaganda would be necessary before public opinion was sufficiently ripe for such a proposal. This, however, is somewhat beside the mark. The question is one which should be considered on its merits, and if it were thought that sterilization would be beneficial to the nation at large it would be our duty to educate public opinion. I am quite sure that none of us who have worked for the cause of defectives in the past, and no member of the Central Association, would shrink from this task.
*This article is being published in pamphlet form. Copies may be obtained from C.A.M,W., 24, Buckingham Palace Road, S.W. 1, at 2d. each or 1/9’doz., post free.
It would appear that those who advocate the sterilization of all mental defectives do so for three main reasons. First, that by preventing- propagation, sterilization would result in a marked decrease of mental deficiency. Secondly, that, by allowing of the discharge of many patients who are now in institutions, it would lessen their cost to the community. Thirdly, that this liberty would increase the happiness of the defectives themselves. The first of these reasons appears to be the chief one actuating those responsible for this propaganda, and a statement made by a recent writer in ” The Spectator ” may probably be reg-arded as typical of their views. This writer says, “It is the only effective method of diminishing the now ever-increasing load of mentally diseased persons.” Leaving aside the assertion regarding the increase of mental disease, which many competent persons deny and which is unsupported by any reliable statistics, let us consider the preventive effect which would be produced by the sterilization of all existing defectives.
Now there is not the slightest doubt that, although a small proportion of cases of defect are not in any way due to inheritance, but are the result of an accidental injury or disease of the child’s brain, yet the great majority of cases are inborn and are due to inheritance. This fact is well established and is now widely known. Consequent on this it has not unnaturally been assumed by those who have no great experience of defectives and who are unacquainted with the subject of heredity, that the mentally defective child must necessarily be the offspring of mentally defective parents. It is of the utmost importance to realise that this is not so, and that the defect of a child may be due to inheritance without its parents being similarly defective. The explanation of this paradox lies in the nature of the inheritance in these cases. Although some writers, chiefly in America, have attempted to prove that Mental Deficiency is due to the absence in the ancestral germ cells, or seed, of certain definite constituents, and that transmission is in accordance with the laws formulated by Mendel, these attempts have been entirely unsuccessful. On the contrary, there is every reason to conclude that mental defect is not to be regarded as resulting from the absence in the seed of a definite item, but as a state of incomplete mental development consequent on the seed having a diminished capacity for growth, to whnt is called a defective developmental potentiality, or a vitiation of the ancestral germ cells. The amount of this vitiation, however, probably varies not only in the germ cells of different individuals of the same stock, but also in the germ cells of the same individual. Moreover, there is reason to think that even with vitiated germ cells the condition of the offspring resulting- therefrom will be to some extent influenced by the nature of the ante- natal environment. The result is that, although the majority of mental defectives come of families whose germ cells have undergone vitiation, this vitiation shows itself in many other ways than mental defect. In some individuals it may be manifest as Dementia Precox or other forms of Dementia. In others, as certain forms of insanity or mental instability. In yet others it may be so slight and the environment of the individual so favourable that it is not manifested at all and he passes through life apparently normal. Nevertheless it is probable that all these classes of persons are ” carriers” of mental defect, inasmuch as a chance combination of adverse circumstances may at any time so increase the impairment of their germ cells as to prevent the normal mental development of their offspring.
It is thus seen that mental defect may be due to inheritance, as it un- doubtedly is in the majority of cases, without the parent or parents of the affected child being- defective. As a matter of fact my own observations show that, in relation to the total number of defectives, the proportion of those who are the offspring of a certifiably defective parent, or parents, is extremely small.
And I have no doubt that this is the general experience of all those who have investigated any considerable number of these cases. This, however, is a very important fact in relation to the preventive effect of the sterilization of defectives.
For it follows that if every defective in existence a generation ago had been sterilized, the number of defectives to-day would not have been appreciably diminished. It also follows that if every defective now existing were to be sterilized the result a generation hence would be insignificant. In short, in order to produce any marked decrease in the total number of mental defectives a generation hence it would be necessary to sterilize, or otherwise prevent the propagation of, not merely those who are themselves defectives, but all those who are ” carriers that is to say, every person suffering from germ vitiation. Obviously, this is not merely impracticable, but it is impossible. It may be added that even could this result be achieved, it is yet practically certain that the factors which initiate that impairment of the germ cells, whose culminating manifestation is mental defect, are still in operation, and that consequently if every individual carrier were eliminated to-day, a fresh crop would soon come into being. We are compelled to conclude, therefore, that from the point of view of prevention, sterilization would not do what is claimed for it and that its results would be relatively slight. In my opinion the eradication of mental defect must of necessity be a slow and gradual process and I believe that it will only be achieved by the removal of those adverse factors of the environment which operate to bring about germ impairment, and by the education of public opinion towards the Eugenic ideal.
Whilst it is necessary to emphasise this point regarding the relatively slight preventive effect which would result from the sterilization of defectives, I wish to make it clear that I do not by any means lightly regard the propagation by defectives which undoubtedly takes place. This is all the more serious for the reason that such progeny are almost invariably sub-normal and in many instances actually defective. It is true that, in proportion to the total number of defectives arising each year, the number so produced is relatively small; but their absolute number is not inconsiderable, and since this addition to the total would certainly be prevented by sterilization the question arises whether it still might not be put into operation with advantage. I think, however, that the disadvantages would far outweigh the advantages, as we shall see in considering the other claims advanced by the advocates of wholesale sterilization.
Their second contention is that, by permitting of the discharge of defectives from institutions, sterilization would greatly decrease their cost to the community.
This is a statistical question, but unfortunately we are without the statistics necessary to make a comparison. For while we know the cost of defectives in institutions we have no sufficiently extensive figures showing their cost outside. It is to be remembered, however, that sterilization will merely prevent propagation. It will not make defectives more stable or more efficient; it will not in any way lessen their social incapacity. Even the mildest grade are defined by statute as ” persons in need of care, supervision and control for their own protection or for the protection of others,” and this need would still exist even were they sterilized and discharged from institutions. What would happen in such a case would be that large numbers of defective men and women, youths and girls, who are now living by no means unhappy lives in well managed institutions, where they have the companionship of their kind, and are engaged in useful and to some extent remunerative work, would again be thrown upon the world to shift for themselves. They would have to compete for a living against their more fortunate normal fellows, in a market already flooded with superfluity of labour; they would again be the butts and tools of the ignorant, designing and unscrupulous; they would have no real companions, and they would inevitably drift into destitution, vice and crime. In other words the liberation of defectives to an extent which would make an appreciable difference to the nation in the cost of their maintenance in Institutions would simply result in a return to the evil days which existed before the passing of the Mental deficiency Act, and those of us who are familiar with those days know only too well how evil they were, and how wretched were the conditions under which thousands of mental defectives existed in this country before 1913. Large numbers of the feeble-minded then lived a harried existence between the workhouse, the refuge, the prison and the streets. Their cost to the community was spread over so many different areas and borne by so many different authorities that it is impossible to say what it amounted to, but there is not the slightest doubt that it was very considerable. And it was a cost accompanied by decided menace to the community, quite apart from any question of propagation, and for which the community received no return. The presence of mental defectives in a nation must always be an uneconomic proposition, but I am disposed to think that, on the whole, institutional care is certainly more economical than Were the conditions which formerly prevailed and which would again prevail were any considerable number of these persons to be discharged from such care. It may be pointed out that the Board of Control have recently given par- ticular attention to the subject of discharge and release on licence of defectives from institutions. In their report for the year 1924 they say, with regard to discharge, ” The failure and consequent need for re-certification of many discharged patients in the past again emphasises the truth that mental deficiency is a permanent condition, and that, in consequence, the mentally defective person requires throughout his life some form of care and protection. Discharge is, therefore, felt to be inexpedient except in very rare cases, where the circumstances in which the patient is discharged are such as to insure his permanent protection.” With regard to release on licence the matter is somewhat different. Liberation is here conditional and the patient can be recalled to the institution should this become necessary. I am in agreement with the Board in considering that certain patients who, as a result of several years’ training, have established good habits and acquired some measure of self-control and who do not display erotic, unstable or violent tendencies, may be released on trial. There are undoubtedly many stable and well-behaved defectives for whom adequate super- vision can be obtained outside institutions. It is important to note, however, that even of the selected cases released on licence a considerable proportion have had to be recalled to institutions.
With regard to this, however, there is another very important point. It is well known that under the conditions which formerly prevailed a considerable amount of promiscuous sexual intercourse took place between defective young women and normal males, and, to a less extent, between high-grade defective males and normal girls. It cannot be doubted that this would have been even much more prevalent had there been no fear of pregnancy and no risk of being mulcted of a weekly charge for the maintenance of offspring. Does any experienced social worker question for a moment that if this fear were removed, owing to these persons having been sterilized, such promiscuous sexual inter- course would be greatly increased ? But it is intercourse of this kind which is the chief means of spreading venereal disease, and I do not think there can he the slightest doubt that the presence in the community of a number of defectives who were known to be incapable of producing children would be followed by a very considerable increase in these diseases. Not only is the feeble-minded girl more amenable to sexual solicitation, but it is well known that her very defect makes her unaware of the danger of venereal disease to her health, oblivious of the need for treatment, and undeterred by the state she is in from responding to further solicitation. The advocates of sterilization may, and do, pooh-pooh this aspect of the question and affect to regard it as a thing which is not at all likely to happen, but I venture to believe that what I have stated will be endorsed by everyone having practical experience of defectives.
The third contention is that sterilization, by permitting their discharge from institutions, would conduce to the greater happiness of defectives. It is perfectly true that a certain number of defectives do resent such detention. They object to the routine and the discipline, they dislike having to do any work, they would much rather be released from all oversight and control and be where they could do exactly what they pleased, how they pleased and when they pleased. Almost invariably, however, these are the very persons who have proved their utter incapacity for social adaptation, who are so fickle and unstable that no one will employ them, and for whom the supervision, against which they fret, is absolutely necessary in their own interests. It is exceedingly doubtful whether such persons would be any happier outside than inside an institution. But cases of this kind are in the minority. It may safely be said that the majority of defectives are by no means unhappy in institutions. On the contrary, institutional life affords far greater opportunities for companionship, recreation and amusement than they would obtain outside, besides shielding them from that constant reminder of inferiority which results from their incapacity to succeed in competition against their normal fellows.
In view of what has been said, I think it will be clear that, as a general policy, the segregation of defectives in suitable colonies or institutions is far preferable to their sterilization. It not only does all that sterilization would do in preventing propagation, but it does more than this ; for it removes the many dangers to society which would arise from their freedom ; it is, on the whole, more conducive to their happiness; it is attended with some amount of remunera- tive return; and it is, in the long run, almost certainly less costly to the State than would be the discharge from care which sterilization would entail.
It has been pointed out, however, that there are many defectives who are stable and well conducted and for whom, after training in institutions, suitable employment can be found outside. In such cases the chief objection to their discharge from institutional care would appear to be the danger of procreation. The question therefore arises whether sterilization might not be made a condition of such discharge, and whether it might be possible, by its application to suitable cases, to reduce considerably the number of persons in institutions. It is obvious that this is a totally different proposition to that of the wholesale and indis- criminate sterilization we have hitherto been considering. It is also one which has received a considerable measure of support from persons having a practical knowledge of defectives; it is therefore worthy of careful and serious consideration.
The first thought which occurs to one is this. If such persons as I have mentioned can be discharged to effective supervision, or if their characters are such that there is no danger of sexual intercourse, then their sterilization is unnecessary. The fact that this operation is considered necessary is proof that sexual intercourse is considered likely; consequently it seems to me that the arguments against it, to which I have already referred, apply here also with equal force. Sterilization would increase the likelihood of sexual intercourse and the spread of venereal diseases.
There is a further practical difficulty. The sterilisation of even such a limited and particular group of cases as is here suggested would necessitate an alteration in the law. It seems to me that it would be practically impossible to devise any legal definitions or regulations which would ensure its limitation to the particular class under consideration. At the present time the demands for the discharge of patients who are quite unsuitable for discharge are very frequent and insistent. They arise from parents, friends, lay committees and authorities responsible for payment. These demands could not fail to be enormously increased and more difficult to resist were sterilization legalised. In the eyes of those who had not carefully considered the matter it would make discharge appear so safe. I have little doubt that, owing to the difficulty of definition and the increasing demand for its application, a method which was intended to be restricted to particular and suitable cases would soon come to be applied generally, with all the disastrous consequences to which I have already referred.
Further, at the present time the amount of institutional accommodation is Woefully inadequate even for cases which are urgently in need of it. The legalisation of sterilization, even in the most restricted form, could not fail to accentuate this want. By giving rise to a false sense of security it would make authorities still more reluctant to provide institutional care and efficient super- vision. Experience has shown that these are the only satisfactory methods of dealing with defectives, and anything which tended to delay or diminish their provision would certainly react to the disadvantage of defectives and the community alike.
It follows that the adoption of wholesale sterilization would result in far more harm than good, and that whilst there are probably some particular cases in which it would be an appropriate and justifiable procedure, the number of these is so relatively small, the practical difficulty of restricting it to them so considerable, and the danger of its extension, and the disastrous consequences which would follow, so great, that we should not risk even the introduction of such a hazardous proposal.
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