The Last Word: Should inpatient psychiatric wards be gender segregated?

CrossCurrents

 

Editorials do not necessarily reflect the views of CAMH.

 

By Dr. Kathy Hegadoren

Historical references conjure up negative images of crowded insane asylums, where men and women segregated by gender were housed for years or decades. Then came the enlightened age of social psychiatry, where social determinants of mental health came to the forefront, prompting re-examination of gender-based segregation of inpatients. If men and women were going to rejoin the “outside world” in a socially acceptance manner, the institutional environment needed to become more “normalized.” This ushered in the movement to establish mixed-gender inpatient units.

Fast forward to the age of deinstitutionalization, where the average lengths of stay began to precipitously fall and where community services were deemed more humane, naturalistic and therapeutic. Large mental health hospitals began to close and inpatient treatment was mostly provided within large urban tertiary care hospitals. Where the average length of stay was four to six weeks, therapy groups could focus on interpersonal skill development and social learning in formal and informal ways. There was an inherent belief that developing communication and self-reflection skills was enhanced or at least made more socially appropriate by a more naturalistic frame­work of mixed male/female groups.

But the average length of stay continued to fall. Hospital closures, increased recognition of mental health emergencies, the emergence of “crisis beds,” day programs and partial hospitalization programs and the development of specialized programs all contributed to shorter lengths of stay. (Currently the average length of stay in many general psychiatry inpatient units is five to seven days.) Group therapy was no longer about systematically developing relational skills because there was not enough time. More and more inpatient stays focused on assessing acute symptoms, modifying drug regimens and providing more individualized therapy targeted at the immediate crisis or circumstance.

Another theme has emerged over the past decade. Recognition has grown that many female inpatients have histories of interpersonal violence. Although psychiatry was slow to respond, it is not surprising that female inpatient units are overrepresented by women with such experiences. It is well recognized that trauma can result in pervasive, long-term impacts on mental health that do not fit neatly into a single DSM-IV category. Relational problems, emotion regulation issues and a fundamental mistrust of others are common. Indeed, women with histories of childhood interpersonal violence often reflect the most complex clinical presentations: They are not stable longitudinally; they respond poorly to drug therapies; they are heavy users of mental health services with limited success and they require long-term multi-modal, highly specialized treatments. Extended time in specific outpatient trauma programs interspersed with short inpatient stays for crisis intervention is typical.

Short average lengths of stay and increased recognition of the relational problems that can arise from histories of trauma have led some to argue for gender-segregated inpatient units. They posit that women will feel safer and will not be triggered as much, especially by men who may have aggressive outbursts or inappropriate social behaviors. Female-only units would provide a therapeutic environment where women could progress on their journey towards wellness.

But before we set out on this course, we need to carefully examine the evidence that this change in policy would actually achieve better care for female inpatients. Some data suggest that men and women do better with different types of psychotherapy, which supports the notion of gender-specific group therapies. Research about adult sequelae of child abuse does suggest that men and women interpret and react to these experiences differently and thus likely need different therapeutic targets. There is growing belief that treatment programs, especially the psychotherapy-based components, may need to consider gender as a determinant of content. In the past, many trauma-related resources had a female bias, almost by default. In terms of childhood interpersonal violence, men are often reluctant to disclose such experiences. More needs to be done to address gender differences in therapies targeted at the profound consequences that can result from interpersonal violence. However, that does not necessarily translate to segregated inpatient units.

Indeed, many questions remain. Will these female-only units be just for women who have experienced violence? Although trauma is overrepresented in the psychiatric population, not all inpatients have experienced it. Will women without trauma feel as comfortable if the main therapeutic focus is trauma? Antepartum and postpartum inpatient units are gender-specific services for women, but are they truly gender-sensitive? I would say they are not.

Moreover, is it true that an all-female unit would be more therapeutic or safer from triggers that evoke powerful emotional and physical reactions? Could not the behaviour of other female inpatients also serve as triggers? Would all staff have to be female? For women with histories of violence, the core issues are often around control, trust and interpersonal relationships. These issues can lead to misinterpretation, ambivalence and conflict from any interaction, regardless of gender. Past family dynamics may have involved conflicts with mothers, such that an all-female staff will not ensure feelings of safety, validation and trustworthiness. Moreover, agency policies, processes regarding admission and discharge, rules of who can be admitted and how long patients can stay may not be totally responsive to the needs of women with trauma.

The historical reasons for desegregation made therapeutic sense at the time and prompted profound improvements in inpatient psychiatric care. More recent developments in psychiatric service delivery have raised questions about the current validity of those reasons. Before we embark on a path to resegregate, we need to be sure we are fully aware and prepared to deal with all the implications.

Dr. Kathy Hegadoren is a professor in the Faculty of Nursing at the University of Alberta and a Canada Research Chair in Stress-Related Disorders in Women.

 

 

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