On the census day (14.09.16), 1322 English young people were detained in secure care; 1260 (95.3%) were placed in England and 62 (4.7%) placed in Wales or Scotland. Just over three quarters of available placements in England were in use on the day of the census. Of the detained young people, 983 (76.9%) were young men, 290 (22.7%) were young women, 5 (0.4%) individuals identified as transgender and 1 (0.1%) as intersex. Data cited below are derived from census questionnaires which were received on 93% of the 1322 young people. There were high response rates, > 85%, across all kinds of unit, except the small number of High Dependency hospital units.
Sociodemographic comparisons of the characteristics of young men and young women in this population are given in Table 1. They are significantly different in terms of age, ethnicity and the presence of any physical illness or disability. Specifically (see Table 1 for additional detail), a larger proportion of the young women detained are aged 15 years or less, and many more of the young men come from a Black and Minority Ethnic Group (BAME) background (a four-fold increase in odds).
While the number of young men with any psychiatric diagnosis (372) was almost double the number of young women (214) with at least one, young women (87.7%) had a 9-fold increase in the odds of having a mental health problem compared with young men (43.6%) and more than double the odds of having three or more mental health morbidities. Risk to self was identified in more than four out of five young women in secure care, a much higher rate than in young men. Risk to others was also more commonly identified in young women, although this reflected the identification of low risk levels in YJS settings where the vast majority of young men were placed. In contrast, young women were less often considered a risk to others than young men in secure hospitals (89/182 or 48.9% versus 69/90 or 76.7%, p < 0.001) while rates were comparable in secure welfare settings (26/52 or 50.0% versus 15/28 or 53.6%, p = 0.761).
While the proportions and actual numbers of young men and young women with any or multiple mental health problems is different, this, on its own, provides no information on the whether or not the pattern of specific mental health problems is the same by gender. This information is equally important as it relates to where an individual might best receive specific treatment and is key to effective service planning and provision.
As Fig. 2 indicates, the populations of young men and young women differed significantly in terms of the likelihood of having a primary diagnosis of psychotic disorders, depressive disorders, eating disorders and emotional dysregulation. Young women had greater odds than young men of having psychotic disorders (15.6% vs 6.8%, OR = 2.53, 95% CI = 1.64, 3.92), depressive disorders (17.6% vs 5.9%, OR = 3.44, 95% CI = 2.22, 5.32), emotional dysregulation (33.2% vs 3.6%, OR = 13.19, 95% CI = 8.44, 20.63) and eating disorders (4.5% vs 0%, OR calculation N/A) but were less frequently diagnosed with ADHD (1.2% vs 11.4%, OR = 0.10, 95% CI = 0.03, 0.3).
Patterns of placement by gender
As Fig. 3 below shows young men and young women are not equally represented in the 3 arms of the system of secure care. Most young women are in the mental health system (192, 66.2%) and a small number in welfare (66, 22.8%). In both these settings, there are more young women than men. The YJS contains the majority of all the young men (848, 86.3%), most of whom are in YOIs (668, 68.0%).
This system is not full but the availability of placements varies by setting, level of security and gender (Fig. 4).
Given the variation in placement capacity across units by gender, and that the populations of young men and young women differ significantly in terms of their mental health profile, it is not particularly surprising to find different ratios of young men and young women across the system, as we demonstrated in Fig. 3. However, in and of themselves, these data do not tell us anything about the appropriateness of placements in terms of mental health needs. It warrants a further analysis to consider whether a young person of a particular gender, with a particular diagnosis is more or less likely to be in a particular kind of placement. The results of this analysis are in Table 2 below.
It is clear from this table that the system responds very differently to young men and young women with the same primary mental health diagnosis. The welfare system detains very few young people with mental health problems. Young women with a mental health problem are more likely to be in hospital than young men (OR = 19.50, CI = 12.39, 30.69); this remains the case even where the young person has multiple (three or more) diagnoses (OR = 12.30, CI = 3.48, 43.44), which could be seen a marker of complexity. More than 70% of young men with a mental health problem are placed in the YJS, predominantly in YOIs, while almost half of the young men with more than three psychiatric diagnoses are placed in the YJS.
Data were then interrogated for diagnosis where the likely management, regardless of offending profile, would be in hospital (psychosis and Learning Disability) or not in hospital (ASC and ADHD). Significant gender differences in placement persisted. A quarter of young men with primary psychosis but only one young woman was in the YJS: all the other young people with psychosis were in hospital. More than half the young men with Learning Disability but only one young woman was in the YJS; most of the other young people with Learning Disability were in hospital. In addition, three quarters of young men with ASC were in the YJS and no young women were. Young women with ASC were almost all in hospital. Nine out of ten young men with ADHD were in the YJS. Close to 90% of young women with primary emotional dysregulation or depression were placed in hospital. In contrast, only about a fifth of young men with the same problems were in hospital, with most placed in the YJS.
While across all secure care institutions, a mental illness diagnosis was significantly less frequent in BAME young men than in white young men (114 or 34.4% vs. 217, 50.0%; χ2 = 18.52; p < 0.001; OR = 0.53, 95% CI = 0.39,0.71), the proportions of BAME and white young men with a primary mental illness diagnosis (excluding ADHD) placed in the YJS were comparable (57/81 or 70.4% vs. 106/167 or 63.5%; χ2 = 1.15; p = 0.283). There was no difference in rates of any mental illness diagnosis between BAME and white young women (27 or 87.1% vs. 154 or 86.5%; p = 0.999) nor any difference in the proportions placed in a secure hospital for those with a diagnosis (excluding ADHD; 21/26 or 80.8% vs. 133/152 or 87.5%; χ2 = 0.86; p = 0.353).