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Evolution of Secure Services for Women in England

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Evolution of Secure Services for Women in England Advances in psychiatric treatment (2011), vol. 17, 323–331 doi: 10.1192/apt.bp.109.007773 Evolution of secure services ARTICLE for women in England Jaydip Sarkar & Mary di Lustro •• variance in the age of onset of schizophrenia, Jaydip Sarkar is a consultant SUMMARY with men being younger than women; forensic psychiatrist working in Patients detained at high and medium security reveal the secure women’s services and •• disparity in the range and severity of symptoms significant gender differences in the presentation of personality disorder services for men (more severe manifestation of post-traumatic at Arnold Lodge in Leicester, UK. psychopathology, mental disorder and social and stress disorder (PTSD) and bipolar disorder in His interests include neurobiology offending profiles. However, secure mental health women); and and affective neuroscience of services in England, like prisons, generally fail to attachment, personality and its recognise the core importance of the differing •• differences in course and prognosis (better disorders, developmental and adult biopsychosocial development in women and the prognosis of schizophrenia in women), response trauma and psychotherapy, mental impact of life experiences on women’s subsequent to treatment and key risk factors (Seeman 1995). health law and gender equality. biopsychosocial functioning. As a consequence, Mary di Lustro is a consultant As regards personality disorder, women receive forensic psychiatrist in the women’s women are often inadequately provided for in disproportionately more diagnoses of his t rionic service at Arnold Lodge medium services dictated by the identified needs, risks secure unit. Her expertise and and dependent personality disorders. Anecdotal and responsiveness of men. The lack of clinically interests are secure services for appropriate facilities for women may account for clinical evidence and DSM-IV-TR (American women, establishment of the the increased frequency with which women are Psychiatric Association 2004) suggest that 75% of women’s enhanced medium secure readmitted to medium security and for their longer patients with personality disorders are women, but service pilot sites, improving gender awareness and enhancing the ability admissions to both high and medium secure care. the rate of borderline personality disorder is the to provide relational security in the New tertiary services are developing as a result same in both genders overall, although with more workforce and the treatment of of the lessons learnt while providing gender-blind severe manifestations in women (Lynam 2007). women with personality disorder. care. However, further development is required to Men have higher rates of most other personality Correspondence Dr Jaydip Sarkar, East Midlands Centre for Forensic ensure that women receive services of the same disorders, with disproportionately high levels quality, range and nature of those received by men. Mental Health, Arnold Lodge, of antisocial and paranoid personality disorder Cordelia Close, Leicester LE5 0LE, DECLARATION OF INTEREST (Lynam 2007). UK. E-mail: jay.sarkar@nottshc. nhs.uk None. Crime and violence There are disparities along gender lines. Women The aim of this article is to highlight core constitute just 6% of the prison population and, differences between the genders, the key factors despite recent increases in the number of violent in terms of needs and the risks associated with crimes committed by women, in 2006 less than 6% various mental disorders. It will trace briefly the were imprisoned for such crimes, compared with evolution of secure services for women and will nearly 95% of men (Home Office 2007). Crime make certain recommendations that could lead to statistics in England and Wales show that men are the provision of responsive, clinically effective and more likely than women to be convicted of a range financially efficient services for women. of violent offences: women are responsible for only 6% of murders, 1.5% of attempted murders, 16% What is different about women? of manslaughters, 7% of woundings and 1.3% of Mental disorder sexual crimes (Home Office 2006). Sexual offences constitute roughly half of all serious violent Gender differences in patients’ manifestation of offences in any one year (Bartlett 2009). psychopathology should be neither surprising Evolutionary salient pressures appear to drive nor controversial. The genders differ in genetics, crime in women. So on one hand, the need to anatomy and hormones determined by evolutionary provide for themselves in a poverty-stricken and pressures. In addition, there are differences in violent environment (Farrington 2004) may fuel psychosocially determined roles – both assigned higher levels of property- and drug-related offences and adopted – within family and sociopolitical in women (Chesney-Lind 1997; Campbell 2001; structures. Psychiatry reflects this. There is: Bartlett 2009). On the other hand, when carrying •• a higher prevalence of substance use disorders in out violent crimes, women are likely to be involved men and mood disorders in women; in ‘low risk’ strategies. There are proportionately 323 Sarkar & di Lustro Hospitals 1999; Sahota 2009). Evidence suggests BOx 1 Gender differences in forensic psychiatry that they are also likely to have harmed their •• Mental disorder: women tend to have •• Deviant behaviour in women is often own children or intimate others rather than higher prevalence and severity of affective conceived of by society (e.g. the criminal strangers (Jurik 1990; Weizmann-Henelius 2003; and trauma-related disorders and receive justice system, the mental health system) Liem 2008). Many women in secure services have more diagnoses of personality disorders to be based on trauma and inadequacy either no index offence or, if they do, are less likely •• Women commit fewer crimes of all types rather than on antisocial personality to have committed violent and sexual offences and tend to target those with whom they disorder (Coid 2000; Maden 2004). Women are also are in an attachment relationship (e.g. •• Women are more likely to receive the comparatively less likely to have prior convictions partners, children, psychiatric staff) in acts Mental Health Act classification of (Steels 1998) and are less likely to reoffend after of interpersonal violence ‘psychopathic disorder’ (which is not discharge (Maden 2006). However, a 2009 study by •• Women tend to receive more mental an ICD-10 category) and to be detained Sahota et al reveals that women committed more health rather than prison disposals when in higher than commensurate levels of violence than men 2 years (38% v . 26%) and 5 years they commit a crime secure care after discharge (49% v . 40%). Within this the rate of arson was much higher in women and increased with the passage of time. The reconviction rate more women represented in simple and aggravated was lower in women (42% v . 50%), although this assaults than in intentional grievous bodily harm is suggested to be an artefact (Sahota 2009). and murder (Kruttschnitt 1993) and weapons Reasons for admission offences (Miller 1986; Steffensmeier 1993). Some of the so-called low-risk strategies appear Many women are admitted to both levels of security to involve targeting intimate others, particularly because of unmanageable self-harm, suicidal acts, their own children or intimate sexual partners aggression towards hospital staff and damage (Weizmann-Henelius 2003; Liem 2008), or dis- to property (Bartlett 2001). This stems from the placement of aggression onto inanimate objects difficulties in managing high rates of suicidal through arson, property damage, etc. Women in behaviour and the use of increasingly restrictive prison have higher rates than men of substance and punitive practices to manage self-harm. use, PTSD, personality disorders and childhood Such patients experience the double jeopardy of sexual abuse. They often have basic literacy skills, being retraumatised by their care-givers through are likely to have been unemployed for the 5 years ‘anti-therapeutic, demeaning and infantilising before imprisonment and to have children at staff attitudes’ (Department of Health 1992), as home (Bartlett 2009). Box 1 summarises gender well as being considered ‘untreatable’ owing to differences found in forensic psychiatry. personality disorders. Men are more likely than women to be detained Features of secure services for women under Part III of the 1983 Act, be subject to restriction orders with a classification of mental Access to services illness, have committed serious violent acts such as A greater proportion of women in high and medium homicide, have a previous forensic history and be security are likely to be detained under Part II admitted because of mental illness or sexually risky of the Mental Health Act 1983 as civil patients behaviours (Women in Secure Hospitals 1999). because most are likely to have been admitted from National Health Service (NHS) facilities Reasons for admission of non-forensic patients rather than prison (Smith 1991; Milne 1995; into secure forensic services Women in Secure Hospitals 1999). Women are Another set of reasons for admission into higher proportion ately more likely to receive a hospital than commensurate levels of security may lie in disposal at court (Sahota 2009). The majority of the hidden risks that some of these women pose women detained in high and medium security with to others (and themselves). One explanation for a personality disorder have primary diagnoses
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