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Safety of women in mixed-sex and single-sex medium secure units: staff and patient perceptions

Published online by Cambridge University Press:  02 January 2018

Gillian Mezey,
Yonette Hassell and
Annie Bartlett
Gillian Mezey*
Affiliation:
St George's, University of London, London, UK
Yonette Hassell
Affiliation:
St George's, University of London, London, UK
Annie Bartlett
Affiliation:
St George's, University of London, London, UK
*
Dr Gillian Mezey, St George's, University of London, Department of Mental Health (Forensic), Jenner Wing, Ground Floor, Cranmer Terrace, London SW17 0RE, UK. Tel: +44(0)208 725 5568; fax: +44(0)208 725 2475; e-mail: gmezey@sgul.ac.uk
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Abstract

Background

The development of single-sex medium secure units for women has been driven by concern about the vulnerability of women to sexual abuse and exploitation in mixed-sex secure settings. Less is known about how women patients and staff perceive gender segregation and their experiences in single-sex units.

Aims

To examine the impact of gender segregation on the safety of women patients detained in medium secure psychiatric facilities.

Method

A qualitative study was conducted involving individual interviews with 58 male and female staff and 31 women patients in single-sex and mixed-sex medium secure units throughout England and Wales.

Results

Women patients in both types of units reported high levels of actual and threatened physical and sexual violence. Women in single-sex units reported intimidation, threats and abuse by other women patients, although they were less vulnerable to sexual abuse and exploitation and serious physical assault.

Conclusions

Further development of single-sex secure units for women may not be justified on the grounds of safety issues alone. Risk assessment of forensic psychiatric patients must include a full assessment of their safety within the psychiatric setting.

Information

Type
Papers
Information
The British Journal of Psychiatry , Volume 187 , Issue 6 , December 2005, pp. 579 - 582
Copyright
Copyright © 2005 The Royal College of Psychiatrists 

It is recognised that women patients in mixed-sex psychiatric settings are vulnerable to threats, harassment and abuse by male patients (Barlow & Wolfson, 1987; Department of Health & Home Office, 1992; Department of Health, 1994; Reference Thomas, Bartlett and MezeyThomas et al, 1995). This has led to UK governmental policy initiatives to increase the provision of single-sex units and wards for psychiatric patients (Department of Health, 1997, 2002, 2003). Women in secure forensic facilities may be particularly vulnerable because so many of them have histories of physical and sexual abuse (Reference Bland, Mezey and DolanBland et al, 1999; Reference Coid, Kahtan and GaultCoid et al, 2000). However, there is little information as to whether women patients consider gender segregation to be either desirable or likely to contribute to their sense of safety (Reference Cleary and WarrenCleary & Warren, 1998; Reference Parry-CookeParry-Cooke, 2000).

The aims of our study were to assess, first, the extent to which women patients in single-sex and mixed-sex medium secure settings consider themselves to be safe, and second, the extent to which the patients’ perceptions of their safety are reflected in the views of staff working within those units.

METHOD

Data were collected from 16 medium secure psychiatric units (11 mixed and 5 single-sex units) located throughout seven National Health Service (NHS) regions in England and Wales. One region was not represented in the study, as its only medium secure unit was no longer accepting women patients. Three units from the private sector and 13 NHS units were included. A total of 126 women patients (56 in mixed-sex and 70 in single-sex units) were invited to participate in the study. Those who consented were interviewed individually and case-note data were collected. Staff participants were purposely selected to provide a representative sample of all clinicians in the units with more than 3 years’ experience. Staff who agreed to participate in the study were interviewed individually.

Both staff and patient interviews were piloted in an NHS medium secure unit that was not included in the final study and were revised accordingly. The interviews with participants were audiotaped, transcribed and coded by independent groups of researchers. A content analysis was conducted to thematically categorise the material from the interviews, to provide a framework for answering the research questions and to allow comparison of interviews across participants (Reference FlickFlick, 2002). The final coding frames included information from both staff and patients on the subject of safety. The material relevant to this paper was further analysed by one of the authors (G.M.) and the analysis was further discussed with Y.H. and A.B. Quotations are used to illustrate the emergent analysis.

RESULTS

Characteristics of participants

Thirty-one women patients were interviewed for the study, a quarter of those invited to take part. Seventeen women were from mixed-sex units and 14 were from single-sex units. The average length of inpatient stay was 2.5 years, with a range of 1 month to 6.5 years. Fifty-eight members of staff (30 from mixed-sex units, 28 from all-women units) participated in the study. The disciplines included 9 consultant forensic psychiatrists, 9 ward managers, 18 staff nurses, 9 nursing support workers, 3 social workers, 5 psychologists and 5 occupational therapists. There were slightly more women staff (53%) than men (47%).

Patient interviews

Perceptions of safety

All the women in the mixed-sex wards said either that they had been physically assaulted or threatened, or that they knew of other patients who had been assaulted or threatened by other patients in their unit. Many patients related their feelings of unsafety to the unstable and potentially violent nature of the whole patient group, rather than specifically the male patients:

‘As I say, a lot of the patients are very, lot of the patients are very, um, well I think they came across as being bad people… er… you know they've done a lotof nasty things and there are a lot of arguments and violence on the ward and stuff like that, you know’ (patient, mixed-sex unit).

However, some women described feeling threatened and intimidated by the fact that they were so outnumbered by male patients. This resulted in some areas of the wards or the garden, where groups of male patients tended to gather, being regarded as ‘out of bounds’:

‘I do find that if I'm in the kitchen there are a group of young men that cook meals together, so there are four or five of them together. And I've started not eating until after they've finished… because I feel a bit nervy and a bit intimidated really. Not from anything they say really, it's just my problem really, you know, but I do find that difficult’ (patient, mixed-sex unit).

‘In the garden… there'll be like four or five boys sitting there, but it's the only place to go’ (patient, mixed-sex unit).

No patient reported feeling threatened by, or unsafe with, staff. However, some patients described staff as failing to respond seriously to complaints of harassment or abuse, or to protect them:

‘I was being harassed by a male patient and… I had to report it because he was continuously harassing me all the time. And the staff, they just kept putting it off, they wouldn't say nothing to him’ (patient, mixed-sex unit).

‘I felt angry and upset… because he was allowed to say what he liked to me and get away with it’ (patient, mixed-sex unit).

‘I did feel safe up until last Wednesday when some guy wanted to kiss me and was trying to get on my bed. And I realised that I'm not that safe because he would have raped me and nobody would have known’ (patient, mixed-sex unit).

Experiences of threat and violence

In the mixed-sex settings, women reported having witnessed male patients masturbating in the lounge area, staff being assaulted by patients, patients being restrained by staff, patients assaulting other patients, and verbal abuse. These experiences contributed to a tense ward atmosphere, in which women were constantly anticipating and watching out for potential threat.

‘X… kept pulling my hair and trying to trip me up and I found that a bit too hard to handle because he was told off about it and and he called me a grass and wouldn't leave me alone after that’ (patient, mixed-sex unit).

‘I have been hit by another patient, the same one who wanted to have sex with me in the showers. When the male patients kick off, then I do tend to be scared of them. They're much more violent and aggressive’ (patient, mixed-sex unit).

‘I have my door locked at night in here because one particular patient came in my room one night and sat on my bed and I was just aware of someone sitting down on my bed. I turned round and it was X sitting and staring at me… I screamed, I nearly died of fright’ (patient, mixed-sex unit).

No woman reported experiences of sexual abuse or harassment by other women in the single-sex units. However, many women complained of bullying, intimidation and aggressive behaviour by other women patients. These experiences ranged from hair-pulling, being prodded and shoved, ‘bitching’ and scapegoating, through to violent assault:

‘That's why I hate being on an all female unit… back biting, slagging each other off, bullying’ (patient, single-sex unit).

‘I got beaten up by two women patients last week and because I am bigger than them, they thought I had started it… I felt scared’ (patient, single-sex unit).

‘I was facing the medicine hatch with my back turned and… X… just come up behind me, said “I want to kill you”, grabbed my hair, punched me in the chin, scratched my neck and got me to the floor’ (patient, single-sex unit).

Gender segregation and perceptions of safety

In spite of widespread reports of experienced and witnessed abuse and violence, most of the women on the mixed-sex wards said they would prefer to be with male patients, rather than in a female-only ward. The unstable and often unpredictable ward environment was generally regarded as inherent to the types of patients who end up in medium secure provision, rather than being exclusively related to male patients.

There was a range of opinions expressed by women in the single-sex units as to whether they were safer than on a mixed-sex unit. One patient, who had recently been assaulted by a male patient at night, did not want to be moved to a women-only ward because of ‘all the bitchiness that goes on’. Another patient commented:

‘I don't feel safe in here at all, people bringing razor blades in, people attacking me, people attacking people all the time. Punching them in the head, kicking them, scratching them. I don't feel safe with the kind of patients that we've got on the unit at all. The kind of patients they're bringing in are very vicious and nasty’ (patient, single-sex unit).

Most women in the single-sex wards thought they were safer in hospital than in the community because they were being prevented from cutting or harming themselves:

Before, people used to be able to slash up [because] they were allowed razors and now all razors have been banned, so I do feel safe. You know, there's nothing I can hurt myself with — well, there is, there's everyday things like plastic and you can ligature yourself with your bra and your knickers even. But as for sharp instruments there aren't any, so I feel safe with the other women, I do not feel I'm going to get attacked… I feel totally safe’ (patient, single-sex unit).

The absence of male patients did not in itself reassure women, or make them feel safer. Indeed, a number of women on the single-sex units felt that the presence of more men on the unit (patients and staff) would increase their sense of safety because ‘males protect you, don't they?’.

In both single-sex and mixed-sex settings, women considered that having more trained staff, fewer agency staff and greater ‘visibility’ of staff in the patient areas and security guards would contribute to their sense of safety. Other factors contributing to their sense of safety included more selective admission criteria in the single-sex units, in particular ensuring that women who were acutely ill or aggressive had a separate admission ward, and providing separate sleeping and washing facilities in the mixed-sex units.

Staff interviews

Perceptions of the safety of women patients

Staff in the single-sex settings tended to regard self-harming behaviour, as well as subtle forms of bullying, coercion and intimidation, as the key safety issues affecting women in single-sex settings:

‘There is bullying that goes on… if you get a couple, two or three of the women who develop an alliance, and they're sort of well respected… feared rather than respected by other women on the ward’ (staff, single-sex unit).

Although many of the staff working in mixed-sex units expressed concern about the vulnerability of women patients to sexual abuse and exploitation by male patients, some of them described the women as being ‘as bad as the men’ in terms of their propensity for violence. Many expressed the view that it was the male patients who needed protection from the women and that, if an incident did occur, it was usually the woman who instigated it and was to blame:

‘The females here, they rule the roost’ (staff, mixed-sex unit).

‘One or two of our female patients frighten the living daylights out of our male patients’ (staff, mixed-sex unit).

‘I think some of the males here are more frightened of the females… they're frightened of their aggression, they're frightened of what they might say… they seem very aware that they have to watch their behaviour… I get the feeling that the chaps are really very careful to make sure they don't lay themselves open to anything that might be said or whatever. I feel in this environment that sometimes the men need protecting more than the females’ (staff, mixed-sex unit).

Staff in the mixed wards were also more inclined than in the single-sex units, to view male patients as needing protection from the sexually provocative and predatory behaviour of the women:

‘She had on like a short cropped top… it wasn't too suitable on a mixed sex ward, so they kind of worked with her to really just cover up a bit more’ (staff, mixed-sex unit).

‘You have to ask yourself how safe the male patients are because this particular female patient has not been averse to finding herself going into the male bedrooms… she's highly sexed, bless her’ (staff, mixed-sex unit).

Attitudes to gender segregation in medium security

Not all staff supported gender segregation in medium security, or considered this necessary in order to protect women. Although staff in single-sex settings were generally positive about gender segregation, as a necessary measure to protect women from sexual abuse and exploitation, a key disadvantage of women-only wards located within mixed-sex units is that, because of their small size, they have to function simultaneously as an admission, rehabilitation and pre-discharge ward. A number of staff considered that this created a potentially unstable and unsafe environment, with acutely disturbed patients being managed alongside patients who were nearing discharge and were more settled.

‘On the ward there isn't enough space, so that if someone gets agitated or hits out, there isn't anywhere for the other women to go. I think it was about three weeks ago, one woman had hit out and the only place that three women could go to escape to was in the toilet and they were advised by staff to stay in the toilet until the woman had been taken to her room’ (staff, single-sex unit).

‘At the moment it's very unsettled, we have two female patients, relatively new admissions, who are very poorly and they are assaulting each other and staff, and trying to attack some of the more stable women as well’ (staff, single-sex unit).

On one single-sex ward, acutely disturbed women patients could only be moved to a ‘de-escalation’ room by walking them through the men's acute ward:

‘I would prefer to have the de-escalation area on here… it just seems beyond belief that if a lady's been disturbed she has to walk through the bedroom corridor on an acute male ward to get to somewhere safe’ (staff, single-sex unit).

In the purpose-built single-sex units there was more scope for women to be transferred across wards according to their stage of rehabilitation and treatment needs.

Staff in the mixed-sex wards were generally in favour of creating ‘women-only’ areas, but only if this could be achieved without disadvantaging the male patients, or restricting their freedom and the opportunities available to them. Although a women-only area was generally considered desirable in principle, it was often too difficult in practice to implement within current space and resource limitations.

‘There isn't any women-only space… attempts to create a women-only space led to a feeling on the part of some staff that it was an infringement of male patients’ needs because they would lose that area’ (staff, mixed-sex unit).

The problem, as identified by one staff member, was not ‘all men’ but specifically predatory men, whose risk to women was recognised and understood. Another respondent suggested that a more appropriate response would be to isolate such high-risk male patients from the women, rather than removing the women to separate units. This would help to convey the message that sexual aggression is related not to maleness per se but only to individual high-risk men, as well as helping to reduce the stigma that some of the patients associated with being placed in a women-only unit.

Factors influencing the safety of women patients

The physical layout of the ward and the organisation of space were identified as key issues contributing to the patients’ perception of, as well as their actual, safety. Many staff on the mixed-sex units felt that women's sense of safety could be enhanced through a more imaginative and flexible use of the available space, for example by ensuring that women's bedrooms were adjacent and in sight of the nursing station.

‘When having a shower or a bath any of the male patients could just walk in… you know, I certainly wouldn't like it, especially when you've got next door somebody who has raped, and that would make me feel very uneasy if I knew about his offence’ (staff, mixed-sex unit).

Other factors identified by staff as necessary for increasing women patients’ sense of safety included the ready availability of alarms, the presence of adequate numbers of trained non-agency staff, having enough women staff on the wards and having a ‘culture of openness’ in which patients were encouraged to voice their concerns to nursing staff and know that they would be taken seriously.

DISCUSSION

The assumption that women patients in secure psychiatric settings will feel safer if they are segregated from the male patients gains only partial support from this study. Although most women patients in the segregated units felt safe, many of them nevertheless stated that they would prefer to be in a mixed-sex ward. Gender segregation was associated in many women's minds with prison and was regarded as ‘abnormal’. Any increased protection that such settings might afford was outweighed by the reputation of women-only units as punitive and stigmatising. Moreover, some women patients said that their sense of safety would be increased if there were more male patients and staff on the ward.

Women are detained in secure psychiatric settings because of their risk of violence and aggression. It should therefore not be surprising if, even when these women are segregated from the men, the ward environment may remain disturbed and at times dangerous. Although women in single-sex units did not generally report feeling safer from physical violence than women in mixed-sex settings, they did seem to feel less vulnerable, in relation to actual or threatened sexual assault and harrassment.

There was a tendency by staff on single-sex units to underestimate the extent of more subtle forms of abuse, intimidation, scapegoating and bullying by other women patients, and by staff on the mixed-sex wards to minimise the extent of women's vulnerability to unwanted sexual approaches by the male patients.

Implications

Although this study was conducted within medium secure forensic psychiatric units, units, we would argue that many of the issues raised are generally applicable to psychiatric patients who are detained in in-patient settings. The question of whether the further development of gender-segregated medium secure provision would enhance the safety of women patients is not straight-forward. Although such segregation might protect women patients from sexual harassment and serious physical assault, it might increase the vulnerability of some patients to other more subtle, but distressing forms of bullying and intimidation.

Separating female from male patients throughout their detention in hospital may simply reinforce the image of men as predatory and dangerous, while not significantly enhancing the women's safety. We need to be able to identify those women who would benefit from being in a single-sex setting, as well as recognising that there may be some women who are at greatest risk from, or towards, other women (Reference AdsheadAdshead, 1994). A further question to be considered is how much choice women should be allowed to exert over the type of setting where they receive treatment (Reference BartlettBartlett, 2003). Although user choice is generally desirable in psychiatric service provision, the fact is that forensic psychiatric patients rarely, if ever, enter treatment voluntarily or have a choice over any aspect of their detention and treatment. It may be that the women who are most damaged may be least capable of protecting themselves, or of recognising and avoiding situations of greatest risk. It is debatable whether or not it would be appropriate or possible to assess the capacity of a woman to take these decisions, or whether the view of the clinical team about what is in her best interest, i.e. to prevent abuse or further exploitation, might override her right to choose in these situations.

Lastly, the clinical implication, and one that is easily addressed, is that risk assessment of all women should include, alongside risk of violence to others, self-harm and suicide, an assessment of their vulnerability to abuse, harassment or exploitation in whatever setting they are placed. Training of staff across all settings should also include raising awareness of issues relating to patients’ safety.

Limitations of the study

To some extent the women patients interviewed in this study were self-selecting and might have had particular concerns around issues of safety and gender segregation in medium security. However, the women were selected from a large number of secure units throughout the country and represented 10% of all women in medium secure care. A further limitation is the lack of any independent corroboration of the women's accounts of specific incidents reported.

Clinical Implications and Limitations

CLINICAL IMPLICATIONS

  1. ▪ Risk assessment of women admitted to medium secure units should include assessment of their vulnerability to abuse or exploitation.

  2. ▪ Staff training should include raising awareness of issues relating to patient safety.

  3. ▪ The degree to which women should exert choice over the setting where they receive treatment is debatable.

LIMITATIONS

  1. ▪ The study sample was to some extent self-selected.

  2. ▪ There was no independent corroboration of the women's accounts of reported incidents.

  3. ▪ The participants might have had particular concerns regarding safety and gender segregation.

Acknowledgements

The research on which this paper is based has been supported by funding from the National Health Service National Programme on Forensic Mental Health Research and Development. However, the views expressed here are those of the authors and not necessarily those of the programme or the Department of Health. We are grateful to Liz Maine, formerly director of Women in Special Hospitals, for her invaluable support and advice in the development of this project.

Footnotes

Declaration of interest

None.

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