Eliminating Seclusion Use for Women in Secure Forensic Hospitals. Are We Doing Enough to Consider Sex and Gender Differences for Elimination?

ABSTRACT

The reduction and eventual elimination of seclusion is a global priority. In 2021, The Royal Commission into Victoria's Mental Health System recommended that seclusion use be eliminated from mental health services within 10 years. This is long needed given human rights concerns and known harms associated with seclusion use. Yet the Commission failed to adequately consider gender‐specific needs of women, and women who may be at increased risk of harms associated with seclusion use. Further, current approaches for seclusion reduction lack an explicit gendered lens. There are noted gendered differences in women and men which can influence how mental ill health and trauma are experienced and expressed. Past experiences of trauma have a large negative impact. For women in secure forensic hospitals, the negative effects of seclusion may be more detrimental in exacerbating harm and trauma. While rates of seclusion are generally declining across general and forensic mental health services, seclusion remains higher in forensic hospitals, and there is a lack of transparency around the rates of seclusion for women. In this paper, the author explores differences between women and men in the context of mental ill health, current approaches for seclusion reduction and whether these adequately consider sex and gender differences. With Victoria approaching the halfway point to the elimination target, the author recommends transparency in reporting of seclusion rates separately for women, and greater focus is paid to the recognition of gender differences in approaches for seclusion reduction and eventual elimination.

1. Aim

The aim of this perspective paper is to examine whether current approaches for seclusion reduction and eventual elimination consider sex‐specific differences between women and men. This discussion is presented in the context of findings from the Royal Commission into Victoria's Mental Health System, specifically recommendation 54, Towards the elimination of seclusion and restraint (Armytage et al. 2021).

2. Background

The safe elimination of seclusion in mental health services is a global priority. While its use aims to contain behaviour and to protect the person and others from imminent and serious harm (Mental Health and Wellbeing Act 2022 (Vic)), it can cause physical and psychological harm, and exacerbate existing trauma (Chieze et al. 2019). The use of seclusion is legislated by the relevant state or territory mental health act, with its use closely monitored, documented and reported (Hem et al. 2018). The Victorian Mental Health and Wellbeing Act (2022) defines seclusion as “the sole confinement of a person to a room or any other enclosed space from which it is not within the control of the person confined to leave” (pg. 24).

There are noted human rights concerns with seclusion use (Chieze et al. 2019); violations related to autonomy, decision making and restrictions in freedom of movement (Chieze et al. 2021). The Convention on the Rights of Persons with Disabilities (United Nations 2006) states “Every person with disabilities has a right to respect for his or her physical and mental integrity on an equal basis with others” (p. 13). For women, the human rights impact as a result of seclusion use is of particular concern. The United Nations (2006) states that women are often subjected to multiple forms of discrimination, subsequently requiring specific, gendered sensitive measures to support their human rights. The impact of human rights breaches for women in forensic mental health may be further compounded by the inherently restrictive (Tomlin et al. 2019) and coercive (Lau et al. 2020) nature of secure forensic hospitals.

Forensic mental health services sit at the intersection of the criminal justice and mental health systems. Secure forensic hospitals provide assessment and treatment for, and management of people with a mental illness, and who present with behaviours that have or may lead to offending (Crocker et al. 2017). Mental health acts regulate the use of restrictive practices, like seclusion, and apply within secure hospitals. As do approaches for seclusion reduction and elimination; this will be explored further in this perspective paper.

The Royal Commission into Victoria's Mental Health System was established in early 2019 to fix Victoria's ‘broken’ mental health system (Armytage et al. 2021). A key focus of The Commission was tasked to address the over reliance on restrictive practices, which includes the use of seclusion and restraint. In 2021, the Commission released their final report, which contained 65 recommendations to transform the mental health system, which the Victorian Government committed to. Recommendation 54, Towards the elimination of seclusion and restraint, centred around the use of restrictive practices in mental health services, with the Commission recommending that the government “…act immediately to reduce the use of seclusion and restraint in mental health and wellbeing service delivery, with the aim to eliminate these practices within 10 years” (Armytage et al. 2021, 297).

Anecdotally, the elimination of restrictive practices was identified as an ambitious target, due to organisational culture and differences in service delivery models, as well as differences in patient demographics and clinical presentations (Newton et al. 2017). Concerns identified relate to pressure on staff to cease using seclusion without alternative environment restrictions, workforce constraints and a lack of education for novice nurses (Snipe and Searby 2023). Most notably, and the focus of this paper, concern extended to the lack of consideration of the needs of specific populations, like women, whose gender‐specific experiences of mental health care, and indeed restrictive practices, were not addressed by The Commission (Maker 2022), yet are often subjected to disproportionate harms. The voice of women has arguably not been heard, especially women in secure forensic hospitals (Hansen, Rosina, Hazelton, Chiu, and Inder 2025). The month of March 2026 will mark the halfway point on the timeframe for Victoria to cease its use of seclusion (and restraint) in mental health services, including secure forensic hospitals. Understanding seclusion reduction progress over the past 5 years is important and may assist in determining what needs to be done for ongoing reduction and to meet the elimination goal.

Since 2021 when The Royal Commission released their recommendations, there have been reductions in the rate of seclusion nationally and internationally, with some variation between use for women and men. Literature generally reflects reductions in seclusion use, nationally (e.g., Barr et al. 2023) and internationally (e.g., Huckshorn 2004; Lau et al. 2020) for both women and men. Studies examining patient characteristics and or sex and gender differences for seclusion use, generally report that males more often experience seclusion compared to women (e.g., Barr et al. 2023; Ham et al. 2025), however this may be a result of fewer women within services, especially in secure forensic hospitals and or the results not separated by women and men.

National Australian data reports five seclusion events per 1000 bed days rate between 2023 and 24, down from 7 events per 1000 bed days between 2020 and 21 (Australian Institute of Health and Welfare 2024). General mental health services also report declines in use for the same periods; 6 and 8 seclusion events per 1000 bed days, retrospectively (Australian Institute of Health and Welfare 2024). Forensic mental health services, also report declines in use, yet remain higher than general settings. Between 2023 and 24, forensic mental health services report 8 events per 1000 bed days, down from 27 events between 2020 and 21 (Australian Institute of Health and Welfare 2024). These declines in use suggest that approaches for seclusion reduction are having a positive effect (e.g., Allan et al. 2017; Ching et al. 2010; Huckshorn 2004).

While recorded reductions in seclusion use are positive, national Australian data fails to report and provide transparency of seclusion use separately for women and men, nor is it publicly available. A Freedom of Information request may be one such avenue to obtain this data, however the custodians of hospital data in Victoria, the Victorian Agency for Healthcare Information, advise that they are “unable to process new data requests from individuals and organisations outside of the Department of Health” (Victorian Agency for Healthcare Information, n.d.). This is problematic given the known differences in how sex and gender shape women and men and the influence that this can have on the development of mental disorders (e.g., Christiansen et al. 2022), how seclusion is used and experienced (Lawrence et al. 2025) and the detrimental impact that seclusion use can have on women, especially with extensive histories of trauma (Hansen, Rosina, Hazelton, and Inder 2025).

3. Design and Method

This perspective paper aims to critically examine sex‐specific differences between women and men and whether current approaches to reduce the use of seclusion consider the sex‐specific differences.

This perspective paper will first explore differences between men and women that may influence the use of seclusion, before critically examining current approaches for seclusion reduction and whether these adequately consider sex specific differences. The position of this discussion is focused around women in forensic mental health settings, who are a highly vulnerable (Bartlett and Hollins 2018) and among the most marginalised populations (Beichner and Hagemann 2022). This paper will then provide clinical practice recommendations that may better support the safe reduction and eventual elimination of seclusion, specifically for women in forensic mental health settings.

The questions guiding this paper will be:

1. What are the sex and gender differences between women and men and how do these influence the use of seclusion?

2. What are common approaches to reduce the use of seclusion in general mental health and secure forensic hospitals?

3. Do approaches to reduce the use and elimination of seclusion consider sex and gender differences?

4. Women and Men Are Different

Sex and gender shape humans in different ways, which can lead to differences in the presentation of mental illness, how they are expressed and experienced (Christiansen et al. 2022), and subsequently what we see in general mental health and secure forensic hospitals. This is influenced by biological, psychological, sociological, and cultural factors, as well as (but not limited to) gender roles and antecedents for trauma.

Generally, women have been found to have higher rates of internalising disorders (e.g., depression, anxiety, eating disorders) (Otten et al. 2021), suicide attempts, and exposure to family, domestic and sexual violence (Australian Institute of Health and Welfare 2025). Men have higher rates of externalising disorders (e.g., antisocial personality disorder, substance use) and completed suicide (Otten et al. 2021). While there is similar prevalence in some disorders (e.g., schizophrenia), there are reported differences in age of onset and severity of symptoms (Christiansen et al. 2022).

Women in the criminal justice and forensic mental health system also have distinct differences, compared to men (de Vogel, Keulen de Vos, et al. 2025; Nicholls et al. 2015). Women have higher rates of mental ill health and substance use (e.g., Bartlett and Hollins 2018) with the impact of these experiences being stronger for women than men (de Vogel and Nicholls 2016). Women have been found to have higher rates of mood disorders (Nicholls et al. 2015) and borderline personality disorder (including traits) (e.g., Grimbos et al. 2016; Hodgins 2022), with a diagnosis of BPD strongly linked to violence risk in women (Grimbos et al. 2016). Women have also been found to have more extensive histories of trauma, victimisation and abuse (e.g., Bartlett et al. 2014; Casey et al. 2020), particularly sexual abuse (de Vogel et al. 2023), with a greater number of adverse childhood experiences among women than men (Streb et al. 2022), that often continue into adulthood (de Vogel, Depla, and Keulen‐de Vos 2025).

While violence in secure forensic hospitals is common (Tulloch et al. 2024) among both women and men, women have been found to be involved in more violence that is more often directed towards staff (de Vogel et al. 2023), and engage in patient aggression and self‐harm (de Vogel et al. 2016), compared to men. Aggression and violence often precipitate seclusion use, with the use of coercive practices reflecting patients at high risk of violence (Flammer et al. 2020).

For women in secure forensic hospitals with such extensive histories of violence and trauma, seclusion is likely to be more psychologically detrimental, compound lifelong trauma, and violent sequelae (King 2023). However, it has been noted that gender is not considered a relevant factor in the use of interventions to manage behaviour (Maker 2020), like seclusion use, which fails to consider the impact of life experiences, particularly the experience of trauma.

5. Approaches for Seclusion Reduction and Elimination

There are various approaches aimed to reduce coercive and restrictive practices, including seclusion use, that are used across general and secure forensic hospitals, with an additional model developed specifically for use in secure forensic hospitals. Current approaches range from meaningful therapeutic engagement, de‐escalation, and sensory modulation to more formalised models and strategies. Safewards (Bowers 2014) and the Six Core Strategies For Reducing Seclusion and Restraint Use (Huckshorn 2004; National Association of State Mental Health Program Directors 2008) are two common examples of more formalised approaches which were developed for use in general mental health settings, with Safewards Secure (Maguire et al. 2024) developed for use in forensic mental health services, including secure forensic hospitals.

The Safewards model aims to reduce risk and coercion by recognising factors across six domains that may result in conflict and/or containment (Bowers 2014). The domains include: “the staff team, the physical environment, outside hospital, the patient community, patient characteristics and the regulatory framework” (Bowers 2014, 499). Across these domains, ‘flashpoints’ may arise which may result in conflict and/or containment (Bowers 2014). For example, within the patient community domain, crowding and noise in the environment may result in conflict that may contribute to an increased risk and use of coercion. The Safewards model describes approaches (such as being present in the environment) for staff to interrupt the link between the flashpoint and the conflict to avoid the use of containment interventions, such as seclusion (Bowers 2014). Safewards Secure was developed for use in forensic mental health services and better acknowledges differences in service settings and service users, such as offending behaviour and longer term care (Maguire et al. 2024). Maguire et al. (2022) note that Safewards secure should not be used in isolation, but rather as an adjunct to the original Safewards model.

The Six Core Strategies For Reducing Seclusion and Restraint Use aim to support an environment that is less coercive and less likely to trigger conflict (National Association of State Mental Health Program Directors 2008). The strategies include organisational approaches across six areas: leadership towards organisational change, the use of data pertaining to seclusion use to inform practice, workforce development, the use of seclusion and restraint prevention tools, consumer roles in inpatient settings, and the use of debriefing techniques (National Association of State Mental Health Program Directors 2008).

Both Safewards and the Six Core Strategies have been successful in reducing conflict and the use of seclusion in general mental health, nationally and internationally (e.g., Bowers et al. 2015; Hamilton et al. 2016; Lebel et al. 2014). While the effectiveness of these approaches in reducing seclusion use in secure forensic hospitals is still being explored, some literature reports varying success in reducing seclusion in this area (Price et al. 2016).

6. Sex/Gender Considerations in Current Approaches for Seclusion Reduction and Elimination

While current approaches for seclusion reduction, such as Safewards and the Six Core Strategies have demonstrated success in supporting seclusion reduction in general mental health settings (e.g., Dickens et al. 2020) and varying success in secure forensic hospitals (Mullen et al. 2022; Price et al. 2016), there is a lack of sex and gender specific considerations in these approaches (Watson et al. 2020). Current approaches also do not explicitly reflect adaptions that may be required or a gendered approach in the training or the evaluation (Watson et al. 2020), minimising the sex and gender specific needs and experiences of women (Maker 2022), especially women in secure forensic hospitals.

Safewards for example, specifically identifies being younger and male as patient characteristics that can give rise to conflict and containment (Bowers 2014). While literature does generally reflect seclusion use is more common among those young in age and male, in both general (e.g., Oster et al. 2016) and secure forensic hospitals (e.g., Hansen et al. 2020), this author posits that the explicit mention of men within such models and approaches for seclusion reduction, risks minimising the distinct pathways and contextual factors that may contribute to women being secluded. This may inadvertently result in sex and gender specific needs for women being overlooked in seclusion reduction and elimination and rather rely on clinicians and or organisations to critically consider sex and gender differences in seclusion use and approaches for reduction. This is important to consider given that the use of restrictive practices, including seclusion, have been found to be used differently with women and men, subsequently requiring different strategies to reduce restrictive practices (Lawrence et al. 2025) that address sex and gender specific differences.

While literature related to women, sex and gender differences between women and men, and importance and need for sex and gender specific ways of working with women in secure forensic hospitals is increasing, further interventions and research need to be done in this space for seclusion reduction and elimination to be successful and gender responsive. Firstly, clinicians working with women in secure forensic hospitals should be both gender sensitive, being aware of gender differences, and be gender‐responsive, taking into account gender differences (de Vogel et al. 2023). Where clinicians have a clear and critical understanding of the gender differences between women and men, gender‐responsive care that is informed by trauma‐informed care and relational ways of working can be enhanced (de Vogel et al. 2023).

The impact of trauma cannot be underestimated for women admitted to secure forensic hospitals. A history of trauma is extensive and often has more of an impact on women in secure forensic hospitals; trauma commences in childhood (Streb et al. 2022) and is perpetuated throughout adulthood (de Vogel, Depla, and Keulen‐de Vos 2025). Literature indicates that women with histories of multiple traumas (Hansen, Rosina, Hazelton, and Inder 2025; Steinert et al. 2007) and specifically sexual and physical abuse in childhood (Hammer et al. 2011) are more likely to experience seclusion. Further, it has been found that experiences of childhood abuse and neglect are predictive of violent behaviour in adulthood (Bland et al. 2018). Therefore, it is imperative for clinicians working with women to consider experiences of trauma and the impact of experiences, especially in the context of reducing (and working towards eliminating) seclusion, given that violence is often a precipitating factor for seclusion use.

Finally, the importance of therapeutic communication and the use of relational security may be more pronounced and have more of an impact on and for women, especially given the higher prevalence of trauma among women than men (de Vogel and Nicholls 2016). For women, increased therapeutic communication and engagement may work to address and avoid interpersonal conflict that may lead to seclusion. This engagement is important, with Hansen, Rosina, Hazelton, Chiu, and Inder (2025) highlighting the impetus for a well‐developed, trusting therapeutic relationship with women, prior, during and post a seclusion event. Seclusion can evoke negative feelings for the woman secluded and impact the therapeutic relationship (Theodoridou et al. 2012). The provision of dignified and ethical care is underpinned by therapeutic and effective engagement and communication (Tulloch et al. 2022) and may contribute to a reduction in seclusion events and duration (Berg et al. 2023). For women admitted to secure forensic hospitals who have highly complex traumatic histories, relationships built on and modelling trust are essential for ongoing elimination strategies. This emphasises the critical need for further research to develop sex and gender specific interventions for women to reduce and ultimately eliminate the use of seclusion in all settings.

7. Conclusion

This perspective paper explored three key areas: (1) sex and gender differences between women and men and how these may influence the use of seclusion, (2) current approaches for seclusion reduction and (3) whether current approaches consider sex and or gender specific differences. These three areas were considered within the context recommendations from Victoria's Royal Commission into Mental Health Services, specifically 54, Towards the elimination of seclusion and restraint, where it was recommended that seclusion (and restraint) be reduced, with the aim to eliminate within 10 years (Armytage et al. 2021).

If elimination in the next 5 years is to be achieved, greater transparency of seclusion related data and reporting is required, especially for discrete populations who may be most at risk. Women admitted to secure forensic hospitals are fewer within this setting but are likely to be most at risk of detrimental harms associated with seclusion as a result of gender differences and complex trauma; therefore, data clarity around use is needed.

The author agrees that gender sensitive and gender responsive care must occur; however, clinicians require advanced education, responsive leadership, and explicit organisational guidance to integrate what is known about the differences between women and men and how these gender specific understandings may influence behaviours that lead to seclusion. This will better support continued seclusion reduction and eventual elimination, subsequently meeting Victoria's aim for elimination by 2031.

8. Relevance for Clinical Practice

This perspective paper stresses the need for gender‐sensitive and gender‐responsive care to be integrated in clinical practice and in continued efforts for seclusion elimination. Mental health nurses are well positioned and play a vital role in these efforts, given their central role in supporting recovery and direct care. For women in secure forensic hospitals, relationships are key and foundational for ongoing seclusion elimination strategies. Sex and gender differences between women and men must be considered if elimination is to be achieved.

Author Contributions

The author had sole contribution for the conception, draft, and revision of this article, and is responsible for all aspects of this work.

Funding

The author has nothing to report.

Ethics Statement

The author has nothing to report.

Conflicts of Interest

The author declares no conflicts of interest.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.