Women in forensic psychiatry

Written by Vivienne de Vogel, PhD,
Head of Research department De Forensische Zorgspecialisten


Violence by women

While women still represent a minority of the forensic psychiatric and prison population, worldwide the number of women committing violent crimes has increased steadily over the past two decades. Moreover, some types of violence, such as intimate partner violence, violence towards one’s own children and inpatient violence by psychiatric patients seem to be as common in women as in men. Most of the research in the forensic field, however, is still devoted to male samples and there are growing concerns about whether the theoretical knowledge we have on factors contributing to violence in men is sufficiently valid and useful for women. Research has demonstrated that the nature of violence differ at least to a certain extent between women and men. Overall, compared to male violence female violence is more indirect, more reactive and within social relationships and less instrument or sexual.


Violence risk assessment in women

Several risk factors for violent behavior in women differ substantially from those in men. For example, it has been found that violence risk factors such as child abuse, adult victimization, disruptions in relationships and families, and economic disadvantages more strongly affect women than men. There are factors for which women have a higher sensitivity, i.e., factors that have a larger effect on later violent or criminal behavior in women than in men (e.g., disruptions in relationships) and factors to which women are more often exposed (e.g., history of sexual victimization). Mental health professionals have recognized these differences and have expressed the need for more specific guidelines for risk assessment in women. Assessment of gender-sensitive risk factors in addition to general risk factors is vital for accurate assessment and management of women’s violence risk. Despite the great advances in risk assessment over the past decades, very few tools have been developed specifically for the assessment of violence risk in females. Moreover, research into the psychometric properties of violence risk assessment tools has been carried out almost exclusively on men. Thus, it can be questioned if these tools are sufficiently adequate for use with women. For example, research results on the predictive accuracy of the widely used Historical Clinical Risk Management-20 (HCR-20) have yielded ambiguous results (see McKeown, 2010).

Recently, gender-sensitive risk assessment guidelines for female (forensic) psychiatric patients in addition to the HCR-20 (or its revision; the HCR-20V3; Douglas et al., 2013) have been developed, the Female Additional Manual (FAM: de Vogel et al., 2012, 2014). The aim of the FAM is to provide mental health professionals with a comprehensive violence risk assessment that offers additional guidelines for risk management in women. The first FAM was published in 2012 as an additional manual to the HCR-20. In 2014, the FAM was entirely adapted to be used with the new HCR-20V3. The FAM contains additional guidelines to two historical items of the HCR-20V3 (Personality disorder and Traumatic experiences) and eight new items with specific relevance to women, for example Prostitution, Parenting difficulties and Low self-esteem. Furthermore, three extra risk ratings were added: the risk of Self-destructive behaviour, Victimization and Non-violent criminal behaviour. Research on the FAM is still limited, but preliminary results show good interrater reliability and predictive validity for violent incidents during treatment. The FAM can be downloaded from www.violencebywomen.com.


Women in forensic psychiatry

The knowledge of effectiveness of forensic treatment for women is very limited and it can be questioned whether or not gender-responsive treatment strategies are needed, especially in mixed treatment settings.In 2012, researchers from four Dutch forensic institutions started a research project into characteristics of female forensic psychiatric patients. The major aim of this ongoing project is to gain more insight into criminal and psychiatric characteristics of female forensic psychiatric patients, especially characteristics that may function as risk or protective factors for future violence. Results may have implications for risk assessment and treatment in forensic psychiatric settings, and possibly also in general psychiatry and/or the penitentiary system. Overall, this may lead to a better understanding of this specific and growing group of forensic patients and enable mental health professionals to provide the most adequate risk assessment and management for women, thereby more effectively preventing violent (re)offending.

An extensive questionnaire, as well as several risk assessment tools were coded based on file information of 275 women who are – or have been admitted to one of four different Dutch forensic psychiatric hospitals. Overall, a picture emerges of severely traumatized women with complex psychopathology, a high level of co-morbidity with multiple previous treatment failures and many incidents during treatment. In a second phase, the results were compared to 275 male forensic patients. Several significant differences were found, for example, women had more often committed homicides and arson and less often sexual offenses, were more often diagnosed with Borderline Personality Disorder (BPD), had more complex histories of victimization and more incidents of violence and self-destructive behavior during treatment.Further comparisons between subgroups of female forensic patients (e.g., relating to psychopathy, BPD, intellectual disabilities, type of offense) and more in-depth analyses of the risk assessment tools are or will be carried out in the near future.


Long-term forensic care

Generally, many female forensic psychiatric patients women have such severe problems that they are admitted in forensic or general psychiatry for an extensive period of time, often even chronically. In the present multicentre study, no differences were found between women and men with respect to mean duration of forensic treatment. However, most of the women did not return completely to society, but to general psychiatric settings or sheltered living accommodations.

For more information and references, please visit: www.violencebywomen.com



de Vogel, V., de Vries Robbé, M., van Kalmthout, W., & Place, C. (2014). Female Additional Manual (FAM). Additional guidelines to the HCR-20V3 for assessing risk for violence in women.English version. Utrecht, The Netherlands: Van der Hoeven Kliniek. Available: www.violencebywomen.com.

Douglas, K.S., Hart, S.D., Webster, C.D., & Belfrage, H. (2013). HCR-20V3: Assessing risk of violence – User guide. Burnaby, Canada: Mental Health, Law, and Policy Institute, Simon Fraser University.

Klein Tuente, S., de Vogel, V., & Stam, J. (2014). Exploring the criminal behavior of women with psychopathy: Results from a multicentre study into psychopathy and violent offending in female forensic psychiatric patients. International Journal of Forensic Mental Health, 13, 1-12.

McKeown, A. (2010). Female offenders: Assessment of risk in forensic settings. Aggression and Violent Behavior, 15, 422-429. doi:10.1016/j.avb.2010.07.004