Would single-sex treatment keep female patients safer?

Analyzing the latest research affecting women.
May 19 2010 9:42 AM

Sexual Assault in the Psychiatric Ward

Would single-sex treatment keep female patients safer?

On Christmas Eve in 2003, an 18-year-old woman with schizophrenia was walking through the ward at Philadelphia's Albert Einstein Medical Center. As she clutched a teddy bear, a male schizophrenic patient grabbed her, brought her into his room, and pushed her on his bed. Then, he and his roommate sexually assaulted her. The three were all patients in the medical center's psychiatric ward, yet no staffer noticed that a patient had been snatched from the hallway in the middle of the day.

If your knowledge of psychiatric wards comes from Girl, Interrupted and One Flew Over the Cuckoo's Nest, it may seem that men and women would be far apart. But very few inpatient units separate men and women, leaving women in the throes of depression, mania, psychosis, or mental breakdown vulnerable to sexual assault from the male patients they share space with.

Torie Bosch Torie Bosch

Torie Bosch is the editor of Future Tense, a project of Slate, the New America Foundation, and Arizona State that looks at the implications of new technologies. 

In addition to the case in Philadelphia, accusations of psychiatric patient-on-patient sexual assault have cropped up over the past few years in California, Oregon, Boston, Florida, Missouri, and elsewhere. In 2007, an estimated 435 inpatients were sexually assaulted in Britain alone, including 15 alleged rapes. A 1997 British study surveyed 50 female in-patients and found that 56 percent had been "pestered by men in any way," 8 percent had "done anything sexually against their will," and 12 percent had "been asked to have sex for favours."

If the chances for sexual assault and harassment are so great, why are mentally ill men and women housed together in the first place? Historically, they weren't. The practice of housing them side-by-side in psychiatric units began sometime around the 1950s and 1960s. The shift was made primarily for therapeutic reasons: The psychiatric community wanted to normalize the hospital environment for patients—if the goal of a psychiatric stay is to prepare a patient to re-enter the "regular" world, he or she should interact with members of both sexes.

As part of the deinstitutionalization movement toward community-based treatment, the purpose of psychiatric units transformed as well. No longer did the severely mentally ill remain in the hospital for decades; instead, people began to check in for brief stays, perhaps a week or two, during an acute episode—a suicide threat or attempt, a severe episode of depression or mania, or a psychotic break. Accordingly, the number of beds available for the mentally ill has fallen drastically. In 1970, there were 524,878 24-hour hospital and residential treatment beds in the United States; in 2002, there were 211,199. So there's less physical space available to devote to sex-segregated spaces.

Recently, an administrator at a Wisconsin mental health facility that has been under investigation for on-site sexual assault defended co-ed housing by saying that the presence of women calms male patients. According to the Milwaukee Journal Sentinel, John Chianelli, administrator of the county's Behavioral Health Division said, "It's a trade-off. … Putting 24 aggressive male patients into a male-only unit would increase the level of violence in the unit." A "trade-off" is a remarkably blasé way to frame what has gone on at Milwaukee County's Mental Health Complex: According to reports, a 22-year-old male patient, whom one medical supervisor called "a very devious sexual predator," assaulted several women; allegedly, he impregnated one and then raped her when she was six weeks pregnant. But there's little research to support Chianelli's claim, beyond a 1996 German study, which noted that staff members of a ward that went from mixed-sex to single-sex observed "a significant increase in annoyance and aggression."

If housing men and women together poses clear dangers for some female patients, especially those who experienced sexual violence prior to hospitalization, why does it continue? The idea that it's therapeutic lingers. And it's also not clear that the patients want to go back to sex-segregation.

Research shows that more female patients than male patients would support a sex-segregated option, though there is no consensus about exactly how the numbers break down. The British study that explored rates of sexual harassment also noted that 52 percent of women preferred female-only wards; another, a 1994 paper from the British Journal of Clinical Psychology, surveyed long-term psychiatric patients and found "that the majority of patients preferred single-sex living." But a 2003 German study from Der Nervenarzt, which looked at the transition of a hospital from sex-segregated to mixed-sex, found that while 25 percent of patients preferred single-sex treatment initially, the number dropped to 9 percent after the change took place. Interestingly, the abstract notes, "Younger patients, voluntarily admitted patients, and those with substance addiction preferred mixed-sex wards."

Even if there were a stronger movement from patients and psychiatrists to develop more single-sex treatment options, the change would not be easy—or cheap. The United Kingdom's National Health Service Executive called in 1999 for an end to mixed-sex wards, vowing to stop their use by 2002. It didn't go so well at first: In January 2009, after a decade of dawdling and seven years after the practice was meant to cease, Health Secretary Alan Johnson set a new goal of finally eliminating mixed-sex units in 2010, threatening to fine hospitals that didn't shape up. The 100 million pound "Privacy and Dignity Fund," part of the Delivering Same-Sex Accommodation program, provided hospitals with funds to rework their layouts, and the Department of Health now declares that most facilities "meet single-sex accommodation standards."

Along with assault, women in mixed-sex wards go through harassment and discomfort that surely don't help their recovery. A relative of mine suffers from bipolar disorder and has been hospitalized several times, in a variety of conditions—units both in wealthy suburban and poorer urban hospitals; entire facilities dedicated to treating the mentally ill. She has never stayed on a women-only ward and has had some truly frightening experiences; one man, she says, "kept telling me we were meant to be together. He crept into my room one night (you were supposed to keep the bedroom doors open and my roommate was catatonic so she was useless) and put his arms around me. I woke up and told him to get out." She wasn't raped—but afterward, she felt more scared and vulnerable when she should have been able to focus on healing. Had she not been able to assert herself, the night could have ended quite differently.

Giving women who are more vulnerable to assault or who are terrified of being in a psychiatric facility the option of same-sex treatment would make their inpatient visits safer, even more productive. This could be particularly important for women who have been the victims of violence, as is the case with so many psychiatric inpatients: The severely mentally ill are far more likely than the mentally healthy to be victims of crime, including sexual violence. One of the few women-only mental health wards is at Toronto's Centre for Addiction and Mental Health, which serves women who, in addition to mental illness, have suffered from traumas like physical or sexual abuse, or addiction. But that unit has just 18 beds.

If female patients don't have the option of single-sex care, then at the very least they deserve to be in the hands of well-trained, caring, and observant staff members. Other safety measures would also be helpful, like an electronic monitoring system, which Florida's St. Joseph Hospital installed after a rape was reported, or giving patients the ability to lock doors if they feel threatened, so long as staff members can override the lock if necessary. A woman who just attempted suicide should be free to get a good night's sleep without worrying about a man crawling into her bed uninvited.

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