Eugenics, institutions and community living

In the first half of the twentieth century a eugenics movement took hold in the United States and parts of Europe. It held that a population's genetic makeup could be improved by controlling who was allowed to have children, and it treated disability as a defect to be bred out. Twenty-seven US states passed laws allowing the compulsory sterilization of people labeled unfit, and in 1927 the US Supreme Court upheld one such law.¹ California sterilized about 20,000 people in its state institutions between 1919 and 1952.² The American movement became a model for the compulsory sterilization program Nazi Germany introduced after 1933, and the US movement waned after the Second World War.¹

Britain never passed a sterilization law of this kind. The Eugenics Society campaigned through the 1920s and 1930s for the voluntary sterilization of people it called mentally deficient or defective, and Parliament voted the bill down in July 1931.³ The same ideas later resurfaced in prenatal and embryo screening, which is covered in Embryo screening, polygenic scores and eugenics fears.

In Nazi Germany, eugenics moved from forced sterilization to killing. A secret child "euthanasia" program began in 1939: doctors, nurses and midwives were required to report infants and young children with disabilities, and parents were encouraged to admit them to clinics that were in fact killing wards, where children died by lethal overdose or starvation. At least 10,000 children were killed.⁴ The adult program, known as Aktion T4 after its Berlin office at Tiergartenstrasse 4, set up six gassing installations and began killing patients in January 1940. The gassings at those six sites were halted in August 1941 after public protest, but the killing continued in decentralized form, by lethal injection and starvation in hospitals and clinics, to the end of the war. Across all its phases, historians estimate the program claimed about 250,000 lives.⁴

Vienna was one of the sites of the program. At the Spiegelgrund children's clinic, 789 victims are recorded, and case files survive for 562 of them.⁵ Hans Asperger worked in the city at the same time; his role is examined in History of the autism diagnosis and is not repeated here.

For much of the twentieth century, disabled people, including many autistic people, were placed in large residential institutions. By the 1950s and 1960s these state and county institutions had reached their peak populations, and conditions were generally poor: residents faced forced labor, harmful medical practices such as lobotomies, and confinement without any need for intensive care.⁶ At the 1967 peak, US public residential facilities with 16 or more residents held an average of 194,650 people with intellectual and developmental disabilities, and another 33,850 lived in state psychiatric facilities.⁶ The practice was not confined to the United States: in the Republic of Ireland, intellectually disabled people continued to be admitted to psychiatric institutions into the 1980s.⁷

Institutions were also sites of reform as well as harm. Utica State Hospital in New York pioneered "moral treatment" in the nineteenth century and later became a case study in how institutionalization, even with good intentions, can reinforce exclusion and harm.⁸ In 1950s and 1960s Britain, autism became a recognized diagnosis through a network of intellectual, institutional and legal changes, and the first epidemiological study in 1966 made the autistic child a scientific and demographic reality.⁹

The closures came slowly and unevenly. In the United States, the Community Mental Health Act of 1963 set up community mental health centers, though its promise was never fully realized,⁶ and the number of Americans with intellectual and developmental disabilities in public residential facilities fell by about 89% between 1980 and 2021.⁶ In England, NHS learning-disability bed provision per 100,000 people fell 98.7% between 1960 and 2020, a steeper fall than for mental-illness beds, which fell 90.6%.¹⁰

The evidence on what the move did for people is mostly positive but limited. A systematic review of 13 studies found that quality of life improved after people moved from institutions into community settings, at up to a year afterward and beyond.¹¹ A later systematic review of people resettled from UK long-stay hospitals found that outcomes generally improve but often level off and rarely reach those of comparable populations, and noted that most studies leave out the voices of the people themselves.¹² The change was contested and varied widely between countries, and historians call for more research into what happened to people after they moved.¹³

A 1999 US Supreme Court decision, Olmstead v. L.C., made unjustified institutional isolation a form of discrimination under the Americans with Disabilities Act. It held that states must place people with mental disabilities in community settings rather than institutions when the state's professionals decide that community placement is appropriate, the person does not oppose it, and the placement can be "reasonably accommodated," taking into account the state's resources and the needs of others.¹⁴

As of October 2026, that framework is under retreat. On 20 July 2026 the US Department of Justice's Civil Rights Division published a notice stating that its 2011 guidance on Olmstead is "not enforceable" and that it will no longer rely on it when enforcing the ADA.¹⁵ The notice does not overturn Olmstead or the ADA itself, and the underlying law remains in force, but it signals a reduced federal appetite for community-integration cases. The change came alongside Texas v. Kennedy, a lawsuit that began in September 2024 as Texas v. Becerra, in which 17 states challenged the 2024 update to the Section 504 rules, including its community-integration provisions; the states dropped their constitutional challenge in April 2025, leaving the integration-mandate dispute.¹⁶ The numbers affected are still large: under the narrowest definition of developmental disability, about 9.8% of US adults with a developmental disability live in a congregate residential setting.¹⁷

As of October 2026, England and Wales have a new law on detention for mental disorder, though most of it is not yet in force. The Mental Health Act 2025 received Royal Assent on 18 December 2025 and amends the Mental Health Act 1983.¹⁸ It separates autism and learning disability from "psychiatric disorder" for the purposes of the Act.¹⁸ It bars detention for compulsory treatment under section 3 on the basis of autism or learning disability alone, puts care and treatment reviews on a statutory footing, and sets up a register of people at risk of detention in England, aiming to prevent unnecessary hospital admissions by improving community services.¹⁹ Most of these provisions do not take effect at Royal Assent; they come into force on a day the Secretary of State appoints by regulations.¹⁸

Some of the harshest practices outlasted the institutions. The Judge Rotenberg Center in Massachusetts, a residential facility, is the only US facility that uses contingent electric skin shock, on people with intellectual and developmental disabilities including autistic people.²⁰ The US Food and Drug Administration banned electrical stimulation devices for self-injurious or aggressive behavior in a final rule published on 6 March 2020, effective 6 April 2020.²¹ The D.C. Circuit court vacated the ban on 6 July 2021, holding that the law at the time did not let the FDA ban a device for some of its intended uses without banning it for all of them.²² Congress then amended the law to allow a ban on specific intended uses, and the FDA proposed the ban again on 26 March 2024; as of October 2026 the rule remained a proposal.²⁰ A task force appointed by the Association for Behavior Analysis International recommended that the right to the shock be upheld for extreme cases under strict oversight; the association's members voted this down and endorsed an alternative position opposing the practice under any condition.²³

Autistic writers describe the institutions plainly. Eric Garcia, an autistic journalist, writes that many institutions were "rife with abuse or negligence," and that for many autistic self-advocates being part of a community, whether living with friends, parents, a home-care worker, a roommate or by oneself, is being "part of the social fabric."^c1 Mel Baggs wrote that "institutions always do grave harm to those who live there," and warned that a move is not enough on its own: what Baggs called "community institutionalization" keeps all the features of an institution, with people "driven from program to program" rather than walking between buildings.^c2

Garcia also records the caution that the move can leave the coercion in place, noting that people who left institutions for community settings with wholly inadequate services did not necessarily gain real freedom.^c1 The critic Dinah Murray argued that facilities given the neutral name "assessment and treatment" units "neither assess nor treat," and instead offer "containment and imprisonment."^c3 The practical alternative autistic writers point to is support that lets people live in homes of their own; the housing and support that exists now is covered in Housing, independent living and homelessness.

Nicolas Joncour, who types to communicate, writes of nonverbal autistic people in France that "they become soulless beings, abandoned in psychiatric hospitals," and describes testimonies of conditions beyond imagining.^c4 Mikel Falvey, who also types to communicate, writes about moving from living with family into a house of his own with roommates and support staff, and about enjoying "every minute of living on my own."^c4