Improving safety for women in psychiatry wards

Most psychiatry units in Australia house male and female patients together. The risks to women in these mixed gender wards are often overlooked. Several studies confirm high rates of sexual assault and harassment of women on psychiatric wards (Frueh et al., 2005). Reported incidents include allegations of rape, with the alleged perpetrator often being another patient, consensual sex, exposure, sexual advances and touching (Cole et al., 2003).

Quote from a woman inpatient:

A really disturbed male patient put his hand over my mouth while I sat in the TV room on the ward.

I tried to kick and scream, but he was on top of me and ripping my clothes.

He kept yelling and swearing at me. A nurse came after ages and he was pulled away.

Even worse was that the nurse said that I shouldn’t have led him on. Nobody believed me or helped me.

Quote from a carer – mother of a woman with bipolar disorder:

I have observed the familiar behaviour, often quite aggressive and sexually explicit, of male patients to female patients. Women in these circumstances are particularly vulnerable and at risk of unwanted pregnancies, infections and overall physical abuse. This is not to say that male patients are not at risk from female patients who make sexual advances to them. Families of either sex who are trying to cope with the existing situations do not need the further burden of such entanglements. Parents, children, husbands and wives of patients need to know that their loved ones will not have to face problems which may arise.

Our recent Royal Australian and New Zealand College of Psychiatrists’ (RANZCP’s) Clinical Practice Guidelines (Galletly et al., 2016) have a special section on issues for women with schizophrenia and related disorders. We remind clinicians about their duty of care to manage their female patients safely, in a setting that promotes recovery.

There is considerable evidence for the association between childhood adversities and psychosis. Many women with psychosis have already been abused, assaulted, exploited or bullied, making them even more vulnerable. The Australian National Survey of High Impact Psychosis (SHIP) study reported that, in the preceding year, 18.3% of women with psychosis had been victims of violence (Morgan et al., 2016). The Clinical Practice Guidelines (Galletly et al., 2016) note high rates of posttraumatic stress disorder (PTSD) in people with psychosis, which can only be aggravated by further trauma while an inpatient.

It is clear that women with psychiatric illnesses are being placed at risk by the existing policy of unisex wards. Pressure for shorter length of stay, and aggression resulting from the use of methamphetamine, has led to an overall increase in symptom severity and behavioural disturbance in these environments. The safety of women inpatients should be addressed as a matter of urgency.

The UK National Patient Safety Agency has published a detailed analysis of mental health safety incidents and recommended a policy of gender segregation on psychiatric wards. In Australia, various ways of addressing safety for women and improving gender-sensitive treatment in inpatient units have been suggested. These include the development of a ‘women friendly environment’, provision of a ‘women only’ sitting rooms in acute inpatient units and single-sex wards.

Over the past decade, different Governments and individual politicians have attempted to highlight the issue of violence against women on psychiatric units. Yet, there is still a lack of uniform policy, funding or guidelines to mandate safe environments. In Australia, priority should be given to upgrading existing facilities. Planning for future hospitals and clinics should be based on offering at least some same-sex accommodation, as this is an essential requirement.

Many factors underpin the lack of change in structures and procedures of psychiatry units. Although housed in mainstream hospitals, they are still hidden from public view. The general public have little knowledge of the dangers for women and are often shocked when told about this. Mental health professionals are inured to the issue because this is how wards have been structured and run for decades; change is too difficult. Patients feel disempowered to speak up, are not believed or cope by denial once discharged. Funding is needed to change ward architecture, and hence, the issue is relegated to a low priority. Furthermore, some staff are concerned that aggression would increase in male-only areas.

A Melbourne study showed that following building works to provide a ‘women-only area’ on a psychiatry inpatient unit, the number of incidents of violence against women fell dramatically (Kulkarni et al., 2014). Mental health staff and administrative concerns were challenged with results showing that gender segregation is both possible and desirable in acute inpatient settings.

The issue of violence against women has received much needed public attention in recent times. We urge all Governments to extend the zero tolerance of violence against women to psychiatry wards.

See Guideline by Galletly et al., 50: 410–472.