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Institute of Psychiatry, London
Departments of Psychiatry, University of Bristol, UK and University of Ioannina School of Medicine, Greece
Department of Psychiatry, University of Bristol, Bristol
Institute of Psychiatry, London
Drugs Analysis and Research, Home Office, London
Broadmoor Hospital, West London Mental Health Trust, Crowthorne, UK
Correspondence: Professor Anthony Maden, Department of Forensic Psychiatry, Academic Centre, West London Mental Health NHS Trust, Southall, Middlesex UB1 3EU, UK. Email: a.maden{at}ic.ac.uk
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ABSTRACT |
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Aims To investigate gender differences in reoffending after discharge from medium-secure psychiatric units.
Method All people discharged from medium-secure units in England and Wales between April 1997 and March 1998 were followed up for 1 year (n=959; 12% women). Reoffending was estimated by collecting reconviction data from the Home Office's Offenders' Index or from files at the mental health unit up to 2 years after discharge.
Results Women were less likely than men to be reconvicted within 2 years of discharge (9% v. 16%, OR=0.49, 95% CI 0.25-0.98). Adjustments for history of self-harm, drug or alcohol problems and previous offending substantially reduced the gender difference. In the full model the OR was 0.97 (95% CI 0.45-2.12).
Conclusions Some or all of the gender differences in reoffending between men and women are explained by self-harm, alcohol and drug problems and previous criminal history.
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INTRODUCTION |
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In a previous paper (Maden et al, 2004) we examined the incidence and risk factors for reoffending in the whole sample. This paper examines data from the same national cohort study to see whether differences in reoffending between men and women exist and if any differences persist after having taken into account the possible confounding factors.
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METHOD |
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Ethical approval for the main study was obtained from South Thames Medical Research Ethics Committee.
Measures
Socio-demographic and clinical variables
Socio-demographic variables and clinical characteristics of the sample were
obtained from the patient notes. We collected information on the following
variables: age at admission, source of referral, main diagnosis, history of
previous admissions to psychiatric hospital, history of physical or sexual
abuse during childhood/adolescence, history of self-harm, history of drug or
alcohol problems.
Follow-up data
Follow-up location data, including readmission to a psychiatric hospital,
were collected for a period of 12 months after discharge or transfer by
writing to the consultant who took over care when the person was discharged or
transferred. When patients had been transferred to other hospitals, data were
collected from the receiving hospital's medical records department.
Forensic data
Background data in relation to the index offence were collected from the
medical records department at each unit. We also recorded the legal status of
the admission (voluntary or involuntary) and the number of previous
convictions. Reoffending was assessed by collecting information on
reconvictions from the Offenders' Index at the Home Office. Data collection
time was extended to 2 years for reconviction data because some offences may
take many months to go to a court, and then there is a further delay between
conviction in a court and recording of this information in the index. However,
less-serious offences committed by people who were not sent to court were not
recorded. In addition, all convictions that appeared in the Index the first 6
months after discharge were manually checked to ensure that they were
referring to new offences committed after discharge and not to the index
offence.
Data analysis
All data analyses were conducted using Stata version 7.0 for Windows. A
non-parametric non-parametric kappa sample test for the equality of medians
evaluated differences in the age at admission and length of stay between women
and men. Pearson's 
2 test was used to test for gender
differences in the various admission, clinical and forensic variables. The
association between gender and reconviction was estimated with a series of
logistic regression models using the logit command in Stata. We used the
robust option of the logit command combined with the cluster option, to take
into account the clustering of the observations within the medium-secure
units. We used reconviction at either the first or the second year (Yes/No) as
the dependent variable. Crude odds ratios (with 95% confidence intervals) were
first obtained for gender; then we entered into the model age and history of
self-harm, physical and sexual abuse, alcohol- and drug-related problems and
the number of previous convictions. A final model adjusted for all these
variables.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONREFERENCES |
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Forensic characteristics
Table 2 shows details of
gender differences in various forensic variables. The forensic profile of men
differed significantly from that of women. Men were more likely to be referred
from prison, and the index offence was more likely to concern property or be
of a sexual nature. Men were also more likely to have two or more previous
convictions and/or previous prison sentences.
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Association between reconviction and gender
Table 3 shows that women
were less likely to be reconvicted compared with men and the crude OR was 0.49
(95% CI 0.25-0.98), that is women were half as likely to be reconvicted
compared with men. We hypothesised that a number of variables would reduce the
gender differences in reconviction, and these models are also presented in
Table 3. Adjustment for
self-harm and number of previous convictions had the strongest effect. In the
final model, adjustment for all variables reduced significantly the gender
differences in reconviction (OR 0.97, 95% CI 0.45-2.12). In this model
significant independent predictors of reconviction were age, self-harm,
history of drug problems and number of previous convictions.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONREFERENCES |
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Comparison with other studies
One of the key findings from the literature review on women and secure
psychiatric services (Lart et al,
1999) was that, although women make up less than one-fifth of the
population in secure settings in Britain, they are a heterogeneous group, with
a wide range of ages and personal, psychiatric and forensic histories. This
was found to be the case in this study. It was also observed in the 1999
review that women in secure psychiatric services have a different pattern of
diagnosis compared with men; in particular, in the medium-secure services they
are more likely to be diagnosed as having a borderline personality disorder
than their male counterparts. Again, this was confirmed in our study.
Lart et al's (1999) review notes the absence of recent outcome studies including women. In high-secure hospital samples, Buchanan (1998) found that gender exerted no independent effect, and Jamieson & Taylor (2004) also showed that there was no statistically significant difference between men and women in the proportion of each reconvicted.
Self-harm and physical or sexual abuse
In terms of levels of self-harm and abuse, there are few studies with which
to compare our data as there is even less clinical detail available on women
in medium security than on women in high security. Bland et al
(1999) described 87 women in
Broadmoor in 1994 and found that nearly 70% had a confirmed or suspected
history of childhood sexual abuse and 94% had a history of self-harm. Heads
et al (1997) found
that for women with schizophrenia in special hospitals, rates of childhood
sexual and physical abuse were significantly higher than for their male
counterparts. A history of self-harm and sexual abuse is more likely in women
(Lart et al, 1999).
Histories of early physical or sexual abuse are particularly common in adults
with a diagnosis of borderline personality disorder, and may represent a final
common pathway for future impulsive and aggressive offending behaviour
(Ogata et al, 1990;
Shearer et al, 1990).
A compulsion to repeat early trauma may be a manifestation of the
re-experiencing phenomena of post-traumatic stress disorder
(Deblinger et al,
1989). Physical abuse and sexual abuse may increase the risk of
violence against others, whereas self-harm is violence against one's self and
may lower the risk for violence against others. Self-harm has been shown to be
associated with a lower risk of reconviction
(Maden et al, 2004),
whereas a history of sexual abuse has been shown to be associated with a
higher risk (Maden et al,
2004).
Alcohol and drug problems
Further, alcohol and drug problems are more common in men and substance
misuse has been shown to be associated with an increased risk of reconviction
(Maden et al, 2004;
Scott et al, 2004).
Bland et al (1999)
found that 38% of their high-secure hospital sample had an alcohol problem and
37% had a drug problem, levels very similar to those found in our study. There
is a well-established link between substance misuse and higher rates of
violence by people with major mental illness
(Arseneault et al,
2000). In a medium-secure hospital sample, Baxter et al
(1999) found that comorbidity,
with conduct disorder or problem alcohol use, doubled reoffending compared
with schizophrenia alone, whereas young age or polydrug use or conduct
disorder increased reconviction rates by factors between 2 and 3.
Previous convictions
It has been shown that the strongest predictor of reoffending is the number
of previous convictions (Bowden,
1981; Black, 1982)
and the current study confirmed that. In our own study women appear to have a
lower risk of being reconvicted because they tend to less often have a history
of previous convictions or of drug problems, and more often have a history of
self-harm.
Limitations of the study
The findings of the present study should be considered in the context of
the following limitations. First, we were not able to record all types of new
offences but only those that led to conviction. Therefore our results cannot
be applied to people committing minor offences. This may underestimate the
real impact of antisocial behaviour in both men and women. Second, data on
reconviction were only obtained from the Offender's Index at the Home Office
and this will be inaccurate. The interval between committing an offence and
being convicted of it in a court is often many months (especially in the case
of those with mental illness), and there is further delay between conviction
in a court and recording of this information in the Index. In order to
minimise this misclassification, we extended the period of data collection for
2 years regarding reconviction. In addition, all convictions that appeared in
the Index within the first 6 months of discharge were manually checked, to
ensure that they were referring to new offences committed after discharge and
not to the index offence. For practical reasons, we were not able to collect
information from other sources such as the national police computer records.
In any case, we think that any misclassification would be more likely to bias
the results towards the null value, i.e. to further reduce the gender
difference in reoffending. Third, medical records, which were usually kept on
the units themselves, were the main source of information related to the index
admission. They provided details of demography, medical and offending history,
source of referral, reason for referral, diagnosis and destination on
discharge. Since the information was not collected for the purposes of this
particular study, a degree of measurement bias is inevitable, particularly
regarding information on self-harm, physical and sexual abuse and drug and
alcohol use. If this bias was not random it could influence the results in
either direction. Last, even in this large cohort of 959 patients, the number
of women was relatively small and the power of the study may have been
compromised.
The government is taking a wide-ranging approach to tackling the inequalities that affect women. The Department of Health's (2002) publication Women's Mental Health: into the Mainstream points out in regard to secure and forensic services that there are differences in the social and offending profiles of women and men, their experience of mental ill health, their patterns of behaviour, and their care and treatment needs. Our study highlights these differences and shows that it is possible to use a number of clinical and forensic variables to assess the risk of future offences in individuals discharged from medium-secure units in the UK. Future studies should try to address whether interventions aimed at reducing the impact of self-harm or abuse in women and of alcohol or drug problems in men could lower the risk of reoffending.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONREFERENCES |
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Baxter, R., Rabe-Hesketh, S. & Parrott, J. (1999) Characteristics, needs and re-offending in a group of patients with schizophrenia formerly treated in medium security. Journal of Forensic Psychiatry, 10, 69-83.
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Received for publication June 22, 2005. Revision received January 16, 2006. Accepted for publication April 3, 2006.
Related articles in BJP:
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| Psychiatric Bulletin | Advances in Psychiatric Treatment | All RCPsych Journals |
