- Email: [email protected]
Gender Considerations in Violence
Gender Considerations in Violence Renee Sorrentino,
MD
a,
*, Susan Hatters Friedman,
MD
b
, Ryan Hall,
MD
c
KEYWORDS Violence Gender Women Intimate partner violence Risk assessment Female stalkers Gender bias KEY POINTS Women account for a minority of the incarcerated population. However, the rate of incarceration in women is increasing. Women are much less likely to be convicted of a violence offense compared with men. Both women and men share the following risk factors for violence: younger age, a history of childhood conduct problems, substance use, and legal history. The gender disparity in violence decreases in the setting of mental illness. Some differences in female sex offenders are higher rates of abuse compared with men, increased likelihood of victimizing biological children, and greater likelihood of engaging in a sexual offense with a codefendant. Women who kill their children most often do so in the context of chronic abuse or neglect. Like men, women may be violent in intimate partner relationships and they have various reasons and motives.
INTRODUCTION
Although women account for only 7% of the incarcerated population, the number is growing.1 Men are more likely to commit acts of violence. However, this may not be true in all settings. Studies have indicated that the gender difference in violence decreases in the setting of mental illness.2 Understanding the gender differences and similarities in violent behaviors helps to establish accurate risk assessment and treatment. The application of gender-informed risk assessments might be instrumental in reducing the risk of future violent behaviors. The role of gender in risk assessment,
Disclosures: The authors have nothing to disclose. a Department of Psychiatry, Harvard School of Medicine, 15 Parkman Street, Boston, MA 02114, USA; b Department of Psychological Medicine, University of Auckland, Auckland Hospital Support Building, Room 12-003, Grafton, Auckland, New Zealand; c Department of Psychiatry, University of Central Florida College of Medicine, University of South Florida, Barry University Dwayne O. Andreas School of Law, 2500 West Lake Mary Boulevard, Lake Mary, FL 32746, USA * Corresponding author. E-mail address: [email protected] Psychiatr Clin N Am - (2016) -–http://dx.doi.org/10.1016/j.psc.2016.07.002 0193-953X/16/ª 2016 Elsevier Inc. All rights reserved.
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sexual offending, intimate partner violence, and child murder is explored in this article. RISK ASSESSMENT IN WOMEN
Violence risk instruments assign a classification for the likelihood that an individual will commit violence (low, moderate, or high risk). Many of these instruments were primarily normed on male prison populations,3 which has led to debate in the literature about whether certain static factors among men (eg, the sex of the victim) accurately predict the likelihood of female-perpetrated violence or reoffense.3–5 However, some research suggests that certain risk factors found among men apply to women as well.3,4,6,7 For example, violence is more likely to be committed by younger individuals whether male or female.3,4,6,7 Similarly, a history of conduct problems as a child, substance use, and legal history are all risk factors that apply to both men and women.3,4,6,7 In addition, there may be specific risk factors for women that assessment instruments do not measure, such as being a victim of intimate partner violence (Box 1). For example, an epidemiologic study done about British women in the community found the following to be the strongest factors for predicting future violence among women: young age, residence in social-assisted housing, history of early conduct problems, being a victim of intimate partner violence, having a history of self-harm behaviors, excessive drinking, and past criminal justice involvement.4 An additional confounding variable for violence risk assessment is mental health history. For example, incarcerated populations often have co-occurring diagnoses such as personality disorders, PTSD, and substance use disorders. When developing assessment instruments, co-occurring diagnoses may cause skewed results compared with the results produced by a general population sample or a sample showing a single disease state such as depression.8 For example, in a recent large Swedish study, Fazel and colleagues9 sought to determine the risk of violent crimes among patients with a recent outpatient diagnosis of depression. As part of the study, the investigators considered an outpatient population diagnosed with depression compared with age-matched controls. The investigators did a secondary analysis involving siblings to try to factor out environmental influences, personality disorders,
Box 1 Domains of risk factors for violence-prone women Childhood adversity: foster care, runaway, unstable family structure Conduct problems: school expulsions, juvenile offenses Living situation: unstable housing, subsidized housing, homelessness Relationships: dysfunctional, unstable, unmarried Past victimization: sexual abuse, victim of intimate partner violence Lifestyle: lifestyle that leads to frequent interactions with police or authorities Adult trauma: victim of crime, traumatic separation Mental health history: depression, anxiety, psychosis, self-harm attempt, personality disorders Substance abuse Data from Yang M, Wong SC, Coid JW. Violence, mental health and violence risk factors among community women: an epidemiological study based on two national household surveys in the UK. BMC Public Health 2013;12:1020.
Gender Considerations in Violence
substance use, violence history, and income levels. Violence was determined based on conviction in the Swedish court system for a violent crime in which there was no plea of not guilty by reason of insanity, and 0.5% of the depressed women committed a violent offense compared with 0.2% of the nondepressed women (odds ratio [OR], 2.8; 95% confidence interval [CI], 2.3–3.3). The rate for depressed men was 3.7%, so depressed women were less likely to be violent than their depressed male counterparts. In review of all the factors associated with a violent crime, this study replicated what many other studies have found: that the most important factors for risk of violence are a history of past violent acts and substance use for both men and women. Note that Fazel and colleagues10 obtained similar results in a comparable study about violent outcomes among individuals with schizophrenia and other related disorders (eg, delusional disorder, schizoaffective disorder, unspecified psychosis) in a Swedish population over age 38. Again the conclusion was that a mental health diagnosis increased the risk for violence for both men and women, especially for individuals with a history of a substance use disorder, criminal behavior, and self-harm attempts. In this study, 2.7% of the women with schizophrenia and other related disorders and 10.7% of the men committed a violent crime within 5 years of being diagnosed. This incidence resulted in an adjusted OR for women with schizophrenia compared with the general population of 14.9 (95% CI, 13.2–16.8). An additional finding of the study is the effect of societal change on the incidences of violence. The investigators found that as the number of days of inpatient hospitalization decreased from the 1970s to the late 2000s, the incidence of violence increased (OR, 5.6%; 95% CI, 2.6%-8.4%; adjusted OR for substances, 5.0%; 95% CI, 1.9% to 7.9%). These results raise the question of how treatment conditions and changes in such conditions over time may affect violence risk assessment. Most of the individuals who committed violent acts were between the ages of 25 and 44 years, and this was consistent with other studies about violence, which found that younger people commit violent acts. However, given the population studied, the correlation between violence and young age may also be related to the phenomenon of positive symptoms of psychosis (eg, hallucinations, delusions) declining with increasing age, resulting in the negative symptoms such as avoidance becoming more prominent over the lifespan of the individual, thus decreasing the risk of violent offenses over time.11 It should also be noted that a potential limitation of both the Fazel and colleagues9,10 studies is that they did not factor in whether the individuals with the diagnoses of depression or schizophrenia received appropriate treatment (eg, whether they accessed appropriate treatment, the frequency of visits, the type of therapy, and doses of medications), or complied with treatment (eg, whether they filled prescriptions or attended appointments). This is important because the MacArthur Study of mental disorder and violence previously found that individuals with mental illness, if complaint with treatment, were at no greater risk of committing violence than the general population.12 The rates reported may only be applicable to populations or health systems with a similar rate of use and treatment to those in Sweden. However, with regard to the context of this article, the research shows that there is a gender difference for the rate of violence that is mediated by mental illness, even if it may be caused more by confounding factors (eg, whether women are more like to obtain treatment or be compliant with treatment of mental illness) than true disease-state differences between genders. As noted in a recent Australian study by Harris and colleagues,13 men with affective, anxiety, or substance use disorders were less likely to seek treatment over a
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1-year period compared with women with the same conditions (aOR, 0.46; 95% CI, 0.30–0.70).10 FEMALE SEX OFFENDERS
Female sex offenders are a poorly understood group. Most sex offender research has been about men. The dearth of research about female sex offenders has resulted in the application of evaluation, treatment, and risk prediction principles from the male sex offender literature. To date, there is insufficient evidence to support the use of male sex offender data for women. Studies estimate that women comprise between 1% and 5% of the total sex offender population.14,15 National statistics about sexual offenders show lower rates of female sex offenders, whereas victim report studies show higher percentages of female offenders.16 International studies based on victimization surveys and official records from Canada, the United Kingdom, the United States, Australia, and New Zealand found that women make up 5% of all sexual offenders.17,18 As with male sex offenders, it is difficult to estimate the true prevalence of female sex offenders. Uniquely, for women, there are cultural and societal stereotypes of women being incapable and uninterested in sexual offending. This stereotype undoubtedly affects the accurate identification of female sex offenders. When female sex offending occurs, it is often perceived as less harmful compared with male offending, or perceived to be initiated by a man. Victims of female perpetrators may be more reluctant to report the abuse because of the relationship with the perpetrator, which is commonly incestuous, as well as the societal perception of women as caretakers and nurturing. However, bias exists in the detection of sexual offenders and is not limited to the general public. The medical and law enforcement communities share the traditional preconception of women as nonviolent nurturers. Biased physicians and police officers do not detect sexual offenses perpetrated by women. As a result, those professions, which could have a role in the detection and prevention of sexual abuse, are not playing that role. The female sex offender research has identified characteristics of offenders and victim variables.19 Offender histories of childhood sexual abuse and intimate partner victimization violence are consistently supported in the literature. Female offenders report abuse histories at an earlier age than male offenders, and experience a longer duration of abuse, greater severity, and higher rates of incest and rape.20,21 Female sex offenders, like female nonsexual offenders, have high rates of psychiatric disorders. Female sex offenders report high rates of mood, anxiety, and substance use disorders.20,22 Fazel and colleagues23 found that one-third of female sex offenders had a past history of psychiatric hospitalization. Studies have not consistently found a difference in psychiatric symptoms or diagnoses when female sex offenders were compared with male offenders. Compared with the general population, female sex offenders have higher rates of psychiatric illness. In one study, between 50% and 75% of women reported a history of intimate partner violence.21,24 Like their male counterparts, limited social supports and intimacy deficits were common in female offenders. Female offenders, like male offenders, often show cognitive distortions or beliefs that minimize sexually abusive behavior. One of the unique replicated findings is that women are more likely than men to commit a sex offense with a male co-offender or as the result of coercion by a man. Most victims of female sex offenders are known to the offender. Studies examining victim characteristics found that women are more likely than men to abuse their biological children or children they have cared for.25 Women are also less discerning of gender when selecting a victim.26 Most studies, although not all, found female sex
Gender Considerations in Violence
offenders to select male and female victims equally. Most victims of female offenders are young (<18 years old), in contrast with male offender victims.27 Overall, male sex offenders have a more extensive criminal history and higher recidivism rate compared with women. Sexual offenses committed by women generally do not involve violent force. Rape is generally defined as penetration of an orifice by an object. Acts of rape are less common among female sex offenders, but, when they occur, the victims tend to be of the same gender, unlike the victims of maleperpetrated rapes.28 Although studies have shown that women rarely engage in rape behavior, the prevalence may be obscured by the gender bias in sexual offending. For example, before 2012, the FBI defined rape as the “carnal knowledge of a female forcibly and against her will.”29 In recognition of this limiting defense, the FBI broadened the definition of rape to “any kind of penetration of another person, regardless of gender, without the victim’s consent.”29 There are cases of female offenders working with male coperpetrators to engage in acts of rape and sexual abuse on adult victims or sexual violence toward children. In these cases, the female offender often aided the male perpetrator. The female perpetrator often would also engage in sexual acts with the male perpetrator in front of the victim.30 It was thought that violent female sexual abusers, especially those who engaged in acts with a male coperpetrator, were under-reported because the women often cooperated with authorities against their male partners or it was assumed by authorities that the female offender was another forced victim. Female rapists who act alone are not well defined in the literature. This group of violent female sex offenders is thought to represent the minority. Attempts to better define female sexual offending have resulted in the classification or typology of female offenders. The typology created by Mathews and colleagues31 (1989) is the most cited. Mathews and colleagues31 described 3 typologies: male coerced, predisposed, and teacher/lover. The male-coerced group refers to women who depend on the male in the relationship. They have histories of sexual abuse and poor relationships. These women participate in sexual offending behavior to maintain the relationship. The predisposed group refers to women who are predisposed to sexual offending because of a history of incest, deviant sexual fantasies, and psychological difficulties. The predisposed female offenders were more likely to abuse their own children or intrafamilial victims. The last group described by Mathews and colleagues31 is teacher/lover. Teacher/lover offenders are often in dysfunctional peer relationships and idealize a relationship with a minor. Most of these women did not consider their behavior to be criminal. Vandiver and Kercher32 described a statistically validated typology from a study of more than 450 female sex offenders. They categorized female sex offenders into 6 groups based on the demographics of victim characteristics and criminal histories. The 6 categories were dominant woman abuse (adult woman abusing adult male), experimented/exploiter (younger offender exploiting a child under her care), babysitter abuse (younger boy assaulted by unrelated female), teacher/lover (teacher abusing student), male-coerced molester (passive offender acting with partner), and male-accompanied offender (active offender acting with partner).32 The largest group, as in the Mathews and colleagues31 study, was the teacher/lover category. This group represented the women who were least likely to have an arrest for a sexual assault.32 These findings dispel the societal myth that women do not commit sexual offenses because of their maternal proclivity to nurture. Rather, it is these women who are in nurturing relationships who may commit sexual offenses. The prevalence of paraphilic disorders among female sex offenders is not known. Most of the literature about paraphilias in women is limited to case studies and small
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samples. Federoff and colleagues33 reviewed 15 female sex offenders using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for paraphilias, and approximately half of the women met criteria for a paraphilia. The most common diagnoses were pedophilia, sexual sadism, and exhibitionism. The prediction of sex offender recidivism among women is difficult given the low base rate and the limited research. Unlike their male counterparts, there are no validated risk assessment instruments for women. The current appraisal of risk to recidivate in women is adopted from the male literature. A study of 380 female sex offenders by Cortoni and Hanson17 found a 5-year recidivism rate of 1%. A meta-analysis of 10 studies consisting of a total of 2490 female sex offenders found a 3% rate of recidivism over 6.5 years.18 The empirically derived risk factors for male sexual recidivism are applied to women without validation. Female sex offenders are rarely violent. However, estimation of the prevalence and characteristics of female sex offenders is poorly understood. Future research in the role of gender in sexual offending should begin to answer these questions. WOMEN PERPETRATORS OF INTIMATE PARTNER VIOLENCE
Women represent approximately 14% of violent offenders. Women are most likely to be violent in the home, toward family.34 Intimate partner violence includes sexual, physical, and emotional abuse. Often it is dangerously conceptualized that women are merely victims, but women may alternatively be the primary aggressor in a heterosexual relationship.35 Violence may be bidirectional. Violence may also occur in homosexual relationships. Violence may occur because of anger, revenge, control, or either paranoid or rational self-defense.36 Female batterers have been described as histrionic, compulsive, or narcissistic.37 Women with severe mental illness may present as intimate partner violence victims, perpetrators, or both.38 Straus39 noted that more than 200 studies have documented that similar percentages of men and women are assaultive toward their partners. Data from the Bureau of Justice Statistics reveals that, in intimate partner violence, 27% of male victims and 18% of female victims have had weapons used against them; 5% of women and 19% of men are hit with an object. It is estimated that half (50%) of female victims and 44% of men are injured by intimate partner violence, with 13% of women and 5% of men experiencing serious injury.40 After being discovered by the legal system, batterers often receive court orders to attend batterer intervention programs. However, these programs often presuppose a single male-oriented mechanism of violence related to a man’s proprietary view of a woman. Because of the single perspective, such programs are unlikely to be effective in other populations. Battered women’s syndrome (BWS), although labeled a syndrome, is used in the legal arena rather than the medical arena as a defense for murder. BWS is based on the model of learned helplessness, in which a woman’s role is that of a passive abuse victim. BWS is used to help juries understand why a woman may kill her abusive partner with excessive force, and when it did not appear to an outsider that she was in imminent danger. When evaluating a woman in the context of intimate partner violence, clinicians should inquire about situations in which there has been violence, precipitants, aggression, and the potential for bidirectional violence.41 If clinicians do not consider that women too may be the aggressors, then issues may not be fully investigated and violence may continue.
Gender Considerations in Violence
WOMEN WHO KILL THEIR CHILDREN
Fathers and mothers murder their children at similar rates overall. Mothers are less likely than fathers to also commit suicide at the time of the child murder.42 In addition, in neonaticide (murder in the first day of life), the culprit is virtually always the mother.35 Both mothers and fathers are most likely to kill their children in the context of chronically abusing or neglecting that child.43 This situation is very different from killing because of a psychotic motive, or in association with suicidality. It is noteworthy that fathers and mothers kill their children at similar rates because, in other types of murder, men predominate by far. Mothers who kill their children are more likely to be shown mercy by courts than fathers who kill their children, both in America and internationally. Infanticide laws exist in 24 nations.43 In general, infanticide laws decrease the penalty from murder to a penalty akin to that for manslaughter, only for mothers who kill their children, and usually only within the first year of life. Mothers are more likely than fathers to be found not guilty by reason of insanity for the crime of child murder.44,45 In light of this, it is important that psychiatrists inquire whether their patients are parents with responsibility for their minor children, because this may not always be considered.46 Clinicians should consider the risk that mentally unwell parents may pose to their young children, as discussed elsewhere in this issue (See Miranda McEwan and Susan Hatters Friedman’s article, “Violence by parents against their children”). Risk of filicide (child murder by parent) related to altruistic or altruistic psychotic motives should be considered among mentally unwell mothers. Forensic interviews after child murder by parents are discussed further elsewhere.42 GENDER BIAS
Gender bias, including stereotypes about gender role, sexual offending, and intimate partner violence, are pervasive in our culture. These biases potentially affect the policing of violent offenses, their legal outcomes, and the management. Studies of the role of gender in the determination of legal outcomes conclude that female defendants receive more lenient sentencing than male defendants. For example, for charges resulting from death, women are more likely than men to be incarcerated for manslaughter rather than murder.1 Although not as extensively studied, gender bias seems to be present in sexual offending and intimate partner violence. As clinicians learn more about the relationship between gender and violence, the gender bias should be replaced by statistically derived data about the role of gender. SUMMARY
The role of gender should be considered in violence prediction. At present, most risk prediction in general and in specific cases such as female sex offenders and intimate partner violence depends on studies in men. However, it is clear that there are specific differences in male and female behaviors that warrant tailored risk assessment tools. The future of accurate prediction of risk should begin with steps toward understanding and uncovering the gender bias in this field. REFERENCES
1. Carson AE, Sabol WJ. Prisoners in 2011. Bureau of Justice Statistics, Office of Justice Programs. US Department of Justice; 2012. 2. Robbins PC, Monahan J, Silver E. Mental disorder, violence, and gender. Law Hum Behav 2003;27(6):561–71.
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3. Friedman SH, Hall RCW, Sorrentino R. Commentary: women, violence and insanity. J Am Acad Psychiatry Law 2013;41(4):523–8. 4. Yang M, Wong SC, Coid JW. Violence, mental health and violence risk factors among community women: an epidemiological study based on two national household surveys in the UK. BMC Public Health 2013;12:1020. 5. Barbaree HE, Langton CM, Peacock EJ. The factor structure of static actuarial items: its relation to prediction. Sex Abuse 2006;18(2):207–26. 6. Siever L. Neurobiology of aggression and violence. Am J Psychiatry 2008;165(4): 429–42. 7. Patrick C. Psychophysiological correlates of aggression and violence: an integrative review. Philos Trans R Soc Lond B Biol Sci 2008;363:2543–55. 8. Friedman SH, Collier S, Hall RCW. PTSD behind bars: incarcerated women and PTSD. In: Martin C, Preedy V, Patel V, editors. Comprehensive guide to posttraumatic stress disorder. Switzerland: Springer International; 2015. 9. Fazel S, Wolf A, Chang Z, et al. Depression and violence: a Swedish population study. Lancet Psychiatry 2015;2(3):224–32. 10. Fazel S, Wolf A, Palm C, et al. Violent crime, suicide, and premature mortality in patients with schizophrenia and related disorders: a 38-year total population study in Sweden. Lancet Psychiatry 2014;1(1):44–54. 11. Swanson JW, Swartz MS, Van Dorn RA, et al. A national study of violent behavior in persons with schizophrenia. Arch Gen Psychiatry 2006;63(5):490–9. 12. Monahan J, Steadman HJ, Silver E, et al. Rethinking risk assessment: the MacArthur study of mental disorder and violence. New York: Oxford University Press; 2001. 13. Harris MG, Baxter AJ, Reavley N, et al. Gender-related patterns and determinants of recent help-seeking for past-year affective, anxiety and substance use disorder: findings from a national epidemiological survey. Epidemiol Psychiatr Sci 2015;2:1–14. 14. Gannon TA, Rose MR. Offence-related interpretative bias in female child molesters: a preliminary study. Sex Abuse 2009;21:194–207. 15. Sandler JC, Freeman NJ. Female sex offender recidivism: a large-scale empirical analysis. Sex Abuse 2009;21(4):455–73. 16. Gannon TA, Cortoni F. Female sexual offenders: theory, assessment and treatment. Chichester (United Kingdom): John Wiley; 2010. 17. Cortoni F, Hanson RK. A review of the recidivism rates of adult female sexual offenders. Research Report No. R-169. Ottawa (Canada): Correctional Service Canada; 2005. 18. Cortoni F, Hanson RK, Coache ME. The recidivism rates of female sexual offenders are low: a meta-analysis. Sex Abuse 2010;22(4):387–401. 19. Johansson-Love J, Fremouw W. Female sex offenders: a controlled comparison of offender and victim/crime characteristics. J Fam Violence 2009;24:367–76. 20. Miccio-Fonseca LC. Adult and adolescent female sex offenders: experiences compared to other female and male sex offenders. J Psychol Human Sex 2000;11(3):75–88. 21. Elliott IA, Eldridge HJ, Ashfield S, et al. Exploring risk: potential static, dynamic, protective and treatment factors in the clinical histories of female sex offenders. J Fam Violence 2010;25:595–602. 22. Steadman HJ, Osher FC, Robbins PC, et al. Prevalence of serious mental illness among jail inmates. Psychiatr Serv 2009;60:761–5. 23. Fazel S, Sjo¨stedt G, Grann M, et al. Sexual offending in women and psychiatric disorder: a national case-control study. Arch Sex Behav 2010;39(1):161–7.
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24. Gannon TA, Rose MR, Ward T. A descriptive model of the offense process for female sexual offenders. Sex Abuse 2008;20(3):352–74. 25. West SG, Friedhman SH, Kim KD. Women accused of sex offenses: a genderbased comparison. Behav Sci Law 2011;29(5):728–40. 26. Gannon TA, Waugh G, Taylor K, et al. Women who sexually offend display three main offense styles: a re-examination of the descriptive model of female sexual offending. Sex Abuse 2014;26(3):207–24. 27. Lewis CF, Stanley CR. Women accused of sexual offenses. Behav Sci Law 2000; 18(1):73–81. 28. Bierie DM, Davis-Siegel J. Measurement matters comparing old and new definitions of rape in federal statistical reporting. Sex Abuse 2015;27(5):443–59. 29. Federal Bureau of Investigation. Crime in the united states 2013: rape. US Government, US Department of Justice. Available at: https://ucr.fbi.gov/crime-in-the-u.s/ 2013/crime-in-the-u.s.-2013/violent-crime/rape/rapemain_final.pdf. Accessed May 5, 2016. 30. Almond L, McManus MA, Giles S, et al. Female sex offenders: an analysis of crime scene behaviors. J Interpers Violence 2015. [Epub ahead of print]. 31. Mathews R, Matthews J, Speltz K. Female sexual offenders: an exploratory study. Brandon (VT): The Safer Society Press; 1989. 32. Vandiver DM, Kercher G. Offender and victim characteristics of registered female sexual offenders in Texas: a proposed typology of female sexual offenders. Sex Abuse 2004;16(2):121–37. 33. Fedoroff PJ, Fishell A, Fedoroff B. A case series of women evaluated for paraphilic sexual disorders. Can J Hum Sex 1999;8(2):127–40. 34. Greenfeld LA, Snell T. Women offenders. Bureau of Justice Statistics Special Report, Office of Justice Programs. US Department of Justice; 2000. 35. Friedman SH. Realistic consideration of women and violence is critical. J Am Acad Psychiatry Law 2015;43(3):273–6. 36. Friedman SH, Loue S, Heaphy E, et al. Intimate partner violence perpetrated by and against Puerto Rican women with severe mental illness. Community Ment Health J 2011;47:156–63. 37. Buttell FP, Carney MM. Women who perpetrate relationship violence: moving beyond political correctness. New York: Hawthorn Press; 2005. 38. Friedman SH, Loue S. Incidence and prevalence of intimate partner violence by and against women with severe mental illness: a review. J Womens Health 2007; 16:471–80. 39. Straus MA. Blaming the messenger for the bad news about partner violence by women: the methodological, theoretical, and value basis of the purported invalidity of the conflict tactics scales. Behav Sci Law 2012;30:538–56. 40. Catalanos S. Intimate partner violence: attributes of victimization. Bureau of Justice Statistics, Office of Justice Programs. US Department of Justice; 2013. 41. Friedman SH, Stankowski J, Loue S. Intimate partner violence and the clinician. In: Simon RI, Tardiff KT, editors. Textbook of Violence Assessment and Management. Arlington (TX): American Psychiatric Publishing; 2008. p. 483–500. 42. Friedman SH, Cavney J, Resnick PJ. Child murder by parents and evolutionary psychology. Psychiatr Clin North Am 2012a;35(4):781–95. 43. Friedman SH, Resnick PJ. Child murder by mothers: patterns and prevention. World Psychiatry 2007;6(3):137–41. 44. Friedman SH, Hrouda D, Holden C, et al. Child murder committed by severely mentally ill mothers: an examination of mothers found not guilty by reason of insanity. J Forensic Sci 2005b;50(6):1466–71.
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45. Friedman SH, Cavney J, Resnick P. Mothers who kill: evolutionary underpinning and law. Behav Sci Law 2012b;30:585–97. 46. Friedman SH, Sorrentino R, Stankowski JE, et al. Psychiatrists’ awareness of maternal filicidal thoughts. Compr Psychiatry 2008;49(1):106–10.
MD
a,
*, Susan Hatters Friedman,
MD
b
, Ryan Hall,
MD
c
KEYWORDS Violence Gender Women Intimate partner violence Risk assessment Female stalkers Gender bias KEY POINTS Women account for a minority of the incarcerated population. However, the rate of incarceration in women is increasing. Women are much less likely to be convicted of a violence offense compared with men. Both women and men share the following risk factors for violence: younger age, a history of childhood conduct problems, substance use, and legal history. The gender disparity in violence decreases in the setting of mental illness. Some differences in female sex offenders are higher rates of abuse compared with men, increased likelihood of victimizing biological children, and greater likelihood of engaging in a sexual offense with a codefendant. Women who kill their children most often do so in the context of chronic abuse or neglect. Like men, women may be violent in intimate partner relationships and they have various reasons and motives.
INTRODUCTION
Although women account for only 7% of the incarcerated population, the number is growing.1 Men are more likely to commit acts of violence. However, this may not be true in all settings. Studies have indicated that the gender difference in violence decreases in the setting of mental illness.2 Understanding the gender differences and similarities in violent behaviors helps to establish accurate risk assessment and treatment. The application of gender-informed risk assessments might be instrumental in reducing the risk of future violent behaviors. The role of gender in risk assessment,
Disclosures: The authors have nothing to disclose. a Department of Psychiatry, Harvard School of Medicine, 15 Parkman Street, Boston, MA 02114, USA; b Department of Psychological Medicine, University of Auckland, Auckland Hospital Support Building, Room 12-003, Grafton, Auckland, New Zealand; c Department of Psychiatry, University of Central Florida College of Medicine, University of South Florida, Barry University Dwayne O. Andreas School of Law, 2500 West Lake Mary Boulevard, Lake Mary, FL 32746, USA * Corresponding author. E-mail address: [email protected] Psychiatr Clin N Am - (2016) -–http://dx.doi.org/10.1016/j.psc.2016.07.002 0193-953X/16/ª 2016 Elsevier Inc. All rights reserved.
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sexual offending, intimate partner violence, and child murder is explored in this article. RISK ASSESSMENT IN WOMEN
Violence risk instruments assign a classification for the likelihood that an individual will commit violence (low, moderate, or high risk). Many of these instruments were primarily normed on male prison populations,3 which has led to debate in the literature about whether certain static factors among men (eg, the sex of the victim) accurately predict the likelihood of female-perpetrated violence or reoffense.3–5 However, some research suggests that certain risk factors found among men apply to women as well.3,4,6,7 For example, violence is more likely to be committed by younger individuals whether male or female.3,4,6,7 Similarly, a history of conduct problems as a child, substance use, and legal history are all risk factors that apply to both men and women.3,4,6,7 In addition, there may be specific risk factors for women that assessment instruments do not measure, such as being a victim of intimate partner violence (Box 1). For example, an epidemiologic study done about British women in the community found the following to be the strongest factors for predicting future violence among women: young age, residence in social-assisted housing, history of early conduct problems, being a victim of intimate partner violence, having a history of self-harm behaviors, excessive drinking, and past criminal justice involvement.4 An additional confounding variable for violence risk assessment is mental health history. For example, incarcerated populations often have co-occurring diagnoses such as personality disorders, PTSD, and substance use disorders. When developing assessment instruments, co-occurring diagnoses may cause skewed results compared with the results produced by a general population sample or a sample showing a single disease state such as depression.8 For example, in a recent large Swedish study, Fazel and colleagues9 sought to determine the risk of violent crimes among patients with a recent outpatient diagnosis of depression. As part of the study, the investigators considered an outpatient population diagnosed with depression compared with age-matched controls. The investigators did a secondary analysis involving siblings to try to factor out environmental influences, personality disorders,
Box 1 Domains of risk factors for violence-prone women Childhood adversity: foster care, runaway, unstable family structure Conduct problems: school expulsions, juvenile offenses Living situation: unstable housing, subsidized housing, homelessness Relationships: dysfunctional, unstable, unmarried Past victimization: sexual abuse, victim of intimate partner violence Lifestyle: lifestyle that leads to frequent interactions with police or authorities Adult trauma: victim of crime, traumatic separation Mental health history: depression, anxiety, psychosis, self-harm attempt, personality disorders Substance abuse Data from Yang M, Wong SC, Coid JW. Violence, mental health and violence risk factors among community women: an epidemiological study based on two national household surveys in the UK. BMC Public Health 2013;12:1020.
Gender Considerations in Violence
substance use, violence history, and income levels. Violence was determined based on conviction in the Swedish court system for a violent crime in which there was no plea of not guilty by reason of insanity, and 0.5% of the depressed women committed a violent offense compared with 0.2% of the nondepressed women (odds ratio [OR], 2.8; 95% confidence interval [CI], 2.3–3.3). The rate for depressed men was 3.7%, so depressed women were less likely to be violent than their depressed male counterparts. In review of all the factors associated with a violent crime, this study replicated what many other studies have found: that the most important factors for risk of violence are a history of past violent acts and substance use for both men and women. Note that Fazel and colleagues10 obtained similar results in a comparable study about violent outcomes among individuals with schizophrenia and other related disorders (eg, delusional disorder, schizoaffective disorder, unspecified psychosis) in a Swedish population over age 38. Again the conclusion was that a mental health diagnosis increased the risk for violence for both men and women, especially for individuals with a history of a substance use disorder, criminal behavior, and self-harm attempts. In this study, 2.7% of the women with schizophrenia and other related disorders and 10.7% of the men committed a violent crime within 5 years of being diagnosed. This incidence resulted in an adjusted OR for women with schizophrenia compared with the general population of 14.9 (95% CI, 13.2–16.8). An additional finding of the study is the effect of societal change on the incidences of violence. The investigators found that as the number of days of inpatient hospitalization decreased from the 1970s to the late 2000s, the incidence of violence increased (OR, 5.6%; 95% CI, 2.6%-8.4%; adjusted OR for substances, 5.0%; 95% CI, 1.9% to 7.9%). These results raise the question of how treatment conditions and changes in such conditions over time may affect violence risk assessment. Most of the individuals who committed violent acts were between the ages of 25 and 44 years, and this was consistent with other studies about violence, which found that younger people commit violent acts. However, given the population studied, the correlation between violence and young age may also be related to the phenomenon of positive symptoms of psychosis (eg, hallucinations, delusions) declining with increasing age, resulting in the negative symptoms such as avoidance becoming more prominent over the lifespan of the individual, thus decreasing the risk of violent offenses over time.11 It should also be noted that a potential limitation of both the Fazel and colleagues9,10 studies is that they did not factor in whether the individuals with the diagnoses of depression or schizophrenia received appropriate treatment (eg, whether they accessed appropriate treatment, the frequency of visits, the type of therapy, and doses of medications), or complied with treatment (eg, whether they filled prescriptions or attended appointments). This is important because the MacArthur Study of mental disorder and violence previously found that individuals with mental illness, if complaint with treatment, were at no greater risk of committing violence than the general population.12 The rates reported may only be applicable to populations or health systems with a similar rate of use and treatment to those in Sweden. However, with regard to the context of this article, the research shows that there is a gender difference for the rate of violence that is mediated by mental illness, even if it may be caused more by confounding factors (eg, whether women are more like to obtain treatment or be compliant with treatment of mental illness) than true disease-state differences between genders. As noted in a recent Australian study by Harris and colleagues,13 men with affective, anxiety, or substance use disorders were less likely to seek treatment over a
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1-year period compared with women with the same conditions (aOR, 0.46; 95% CI, 0.30–0.70).10 FEMALE SEX OFFENDERS
Female sex offenders are a poorly understood group. Most sex offender research has been about men. The dearth of research about female sex offenders has resulted in the application of evaluation, treatment, and risk prediction principles from the male sex offender literature. To date, there is insufficient evidence to support the use of male sex offender data for women. Studies estimate that women comprise between 1% and 5% of the total sex offender population.14,15 National statistics about sexual offenders show lower rates of female sex offenders, whereas victim report studies show higher percentages of female offenders.16 International studies based on victimization surveys and official records from Canada, the United Kingdom, the United States, Australia, and New Zealand found that women make up 5% of all sexual offenders.17,18 As with male sex offenders, it is difficult to estimate the true prevalence of female sex offenders. Uniquely, for women, there are cultural and societal stereotypes of women being incapable and uninterested in sexual offending. This stereotype undoubtedly affects the accurate identification of female sex offenders. When female sex offending occurs, it is often perceived as less harmful compared with male offending, or perceived to be initiated by a man. Victims of female perpetrators may be more reluctant to report the abuse because of the relationship with the perpetrator, which is commonly incestuous, as well as the societal perception of women as caretakers and nurturing. However, bias exists in the detection of sexual offenders and is not limited to the general public. The medical and law enforcement communities share the traditional preconception of women as nonviolent nurturers. Biased physicians and police officers do not detect sexual offenses perpetrated by women. As a result, those professions, which could have a role in the detection and prevention of sexual abuse, are not playing that role. The female sex offender research has identified characteristics of offenders and victim variables.19 Offender histories of childhood sexual abuse and intimate partner victimization violence are consistently supported in the literature. Female offenders report abuse histories at an earlier age than male offenders, and experience a longer duration of abuse, greater severity, and higher rates of incest and rape.20,21 Female sex offenders, like female nonsexual offenders, have high rates of psychiatric disorders. Female sex offenders report high rates of mood, anxiety, and substance use disorders.20,22 Fazel and colleagues23 found that one-third of female sex offenders had a past history of psychiatric hospitalization. Studies have not consistently found a difference in psychiatric symptoms or diagnoses when female sex offenders were compared with male offenders. Compared with the general population, female sex offenders have higher rates of psychiatric illness. In one study, between 50% and 75% of women reported a history of intimate partner violence.21,24 Like their male counterparts, limited social supports and intimacy deficits were common in female offenders. Female offenders, like male offenders, often show cognitive distortions or beliefs that minimize sexually abusive behavior. One of the unique replicated findings is that women are more likely than men to commit a sex offense with a male co-offender or as the result of coercion by a man. Most victims of female sex offenders are known to the offender. Studies examining victim characteristics found that women are more likely than men to abuse their biological children or children they have cared for.25 Women are also less discerning of gender when selecting a victim.26 Most studies, although not all, found female sex
Gender Considerations in Violence
offenders to select male and female victims equally. Most victims of female offenders are young (<18 years old), in contrast with male offender victims.27 Overall, male sex offenders have a more extensive criminal history and higher recidivism rate compared with women. Sexual offenses committed by women generally do not involve violent force. Rape is generally defined as penetration of an orifice by an object. Acts of rape are less common among female sex offenders, but, when they occur, the victims tend to be of the same gender, unlike the victims of maleperpetrated rapes.28 Although studies have shown that women rarely engage in rape behavior, the prevalence may be obscured by the gender bias in sexual offending. For example, before 2012, the FBI defined rape as the “carnal knowledge of a female forcibly and against her will.”29 In recognition of this limiting defense, the FBI broadened the definition of rape to “any kind of penetration of another person, regardless of gender, without the victim’s consent.”29 There are cases of female offenders working with male coperpetrators to engage in acts of rape and sexual abuse on adult victims or sexual violence toward children. In these cases, the female offender often aided the male perpetrator. The female perpetrator often would also engage in sexual acts with the male perpetrator in front of the victim.30 It was thought that violent female sexual abusers, especially those who engaged in acts with a male coperpetrator, were under-reported because the women often cooperated with authorities against their male partners or it was assumed by authorities that the female offender was another forced victim. Female rapists who act alone are not well defined in the literature. This group of violent female sex offenders is thought to represent the minority. Attempts to better define female sexual offending have resulted in the classification or typology of female offenders. The typology created by Mathews and colleagues31 (1989) is the most cited. Mathews and colleagues31 described 3 typologies: male coerced, predisposed, and teacher/lover. The male-coerced group refers to women who depend on the male in the relationship. They have histories of sexual abuse and poor relationships. These women participate in sexual offending behavior to maintain the relationship. The predisposed group refers to women who are predisposed to sexual offending because of a history of incest, deviant sexual fantasies, and psychological difficulties. The predisposed female offenders were more likely to abuse their own children or intrafamilial victims. The last group described by Mathews and colleagues31 is teacher/lover. Teacher/lover offenders are often in dysfunctional peer relationships and idealize a relationship with a minor. Most of these women did not consider their behavior to be criminal. Vandiver and Kercher32 described a statistically validated typology from a study of more than 450 female sex offenders. They categorized female sex offenders into 6 groups based on the demographics of victim characteristics and criminal histories. The 6 categories were dominant woman abuse (adult woman abusing adult male), experimented/exploiter (younger offender exploiting a child under her care), babysitter abuse (younger boy assaulted by unrelated female), teacher/lover (teacher abusing student), male-coerced molester (passive offender acting with partner), and male-accompanied offender (active offender acting with partner).32 The largest group, as in the Mathews and colleagues31 study, was the teacher/lover category. This group represented the women who were least likely to have an arrest for a sexual assault.32 These findings dispel the societal myth that women do not commit sexual offenses because of their maternal proclivity to nurture. Rather, it is these women who are in nurturing relationships who may commit sexual offenses. The prevalence of paraphilic disorders among female sex offenders is not known. Most of the literature about paraphilias in women is limited to case studies and small
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samples. Federoff and colleagues33 reviewed 15 female sex offenders using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for paraphilias, and approximately half of the women met criteria for a paraphilia. The most common diagnoses were pedophilia, sexual sadism, and exhibitionism. The prediction of sex offender recidivism among women is difficult given the low base rate and the limited research. Unlike their male counterparts, there are no validated risk assessment instruments for women. The current appraisal of risk to recidivate in women is adopted from the male literature. A study of 380 female sex offenders by Cortoni and Hanson17 found a 5-year recidivism rate of 1%. A meta-analysis of 10 studies consisting of a total of 2490 female sex offenders found a 3% rate of recidivism over 6.5 years.18 The empirically derived risk factors for male sexual recidivism are applied to women without validation. Female sex offenders are rarely violent. However, estimation of the prevalence and characteristics of female sex offenders is poorly understood. Future research in the role of gender in sexual offending should begin to answer these questions. WOMEN PERPETRATORS OF INTIMATE PARTNER VIOLENCE
Women represent approximately 14% of violent offenders. Women are most likely to be violent in the home, toward family.34 Intimate partner violence includes sexual, physical, and emotional abuse. Often it is dangerously conceptualized that women are merely victims, but women may alternatively be the primary aggressor in a heterosexual relationship.35 Violence may be bidirectional. Violence may also occur in homosexual relationships. Violence may occur because of anger, revenge, control, or either paranoid or rational self-defense.36 Female batterers have been described as histrionic, compulsive, or narcissistic.37 Women with severe mental illness may present as intimate partner violence victims, perpetrators, or both.38 Straus39 noted that more than 200 studies have documented that similar percentages of men and women are assaultive toward their partners. Data from the Bureau of Justice Statistics reveals that, in intimate partner violence, 27% of male victims and 18% of female victims have had weapons used against them; 5% of women and 19% of men are hit with an object. It is estimated that half (50%) of female victims and 44% of men are injured by intimate partner violence, with 13% of women and 5% of men experiencing serious injury.40 After being discovered by the legal system, batterers often receive court orders to attend batterer intervention programs. However, these programs often presuppose a single male-oriented mechanism of violence related to a man’s proprietary view of a woman. Because of the single perspective, such programs are unlikely to be effective in other populations. Battered women’s syndrome (BWS), although labeled a syndrome, is used in the legal arena rather than the medical arena as a defense for murder. BWS is based on the model of learned helplessness, in which a woman’s role is that of a passive abuse victim. BWS is used to help juries understand why a woman may kill her abusive partner with excessive force, and when it did not appear to an outsider that she was in imminent danger. When evaluating a woman in the context of intimate partner violence, clinicians should inquire about situations in which there has been violence, precipitants, aggression, and the potential for bidirectional violence.41 If clinicians do not consider that women too may be the aggressors, then issues may not be fully investigated and violence may continue.
Gender Considerations in Violence
WOMEN WHO KILL THEIR CHILDREN
Fathers and mothers murder their children at similar rates overall. Mothers are less likely than fathers to also commit suicide at the time of the child murder.42 In addition, in neonaticide (murder in the first day of life), the culprit is virtually always the mother.35 Both mothers and fathers are most likely to kill their children in the context of chronically abusing or neglecting that child.43 This situation is very different from killing because of a psychotic motive, or in association with suicidality. It is noteworthy that fathers and mothers kill their children at similar rates because, in other types of murder, men predominate by far. Mothers who kill their children are more likely to be shown mercy by courts than fathers who kill their children, both in America and internationally. Infanticide laws exist in 24 nations.43 In general, infanticide laws decrease the penalty from murder to a penalty akin to that for manslaughter, only for mothers who kill their children, and usually only within the first year of life. Mothers are more likely than fathers to be found not guilty by reason of insanity for the crime of child murder.44,45 In light of this, it is important that psychiatrists inquire whether their patients are parents with responsibility for their minor children, because this may not always be considered.46 Clinicians should consider the risk that mentally unwell parents may pose to their young children, as discussed elsewhere in this issue (See Miranda McEwan and Susan Hatters Friedman’s article, “Violence by parents against their children”). Risk of filicide (child murder by parent) related to altruistic or altruistic psychotic motives should be considered among mentally unwell mothers. Forensic interviews after child murder by parents are discussed further elsewhere.42 GENDER BIAS
Gender bias, including stereotypes about gender role, sexual offending, and intimate partner violence, are pervasive in our culture. These biases potentially affect the policing of violent offenses, their legal outcomes, and the management. Studies of the role of gender in the determination of legal outcomes conclude that female defendants receive more lenient sentencing than male defendants. For example, for charges resulting from death, women are more likely than men to be incarcerated for manslaughter rather than murder.1 Although not as extensively studied, gender bias seems to be present in sexual offending and intimate partner violence. As clinicians learn more about the relationship between gender and violence, the gender bias should be replaced by statistically derived data about the role of gender. SUMMARY
The role of gender should be considered in violence prediction. At present, most risk prediction in general and in specific cases such as female sex offenders and intimate partner violence depends on studies in men. However, it is clear that there are specific differences in male and female behaviors that warrant tailored risk assessment tools. The future of accurate prediction of risk should begin with steps toward understanding and uncovering the gender bias in this field. REFERENCES
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3. Friedman SH, Hall RCW, Sorrentino R. Commentary: women, violence and insanity. J Am Acad Psychiatry Law 2013;41(4):523–8. 4. Yang M, Wong SC, Coid JW. Violence, mental health and violence risk factors among community women: an epidemiological study based on two national household surveys in the UK. BMC Public Health 2013;12:1020. 5. Barbaree HE, Langton CM, Peacock EJ. The factor structure of static actuarial items: its relation to prediction. Sex Abuse 2006;18(2):207–26. 6. Siever L. Neurobiology of aggression and violence. Am J Psychiatry 2008;165(4): 429–42. 7. Patrick C. Psychophysiological correlates of aggression and violence: an integrative review. Philos Trans R Soc Lond B Biol Sci 2008;363:2543–55. 8. Friedman SH, Collier S, Hall RCW. PTSD behind bars: incarcerated women and PTSD. In: Martin C, Preedy V, Patel V, editors. Comprehensive guide to posttraumatic stress disorder. Switzerland: Springer International; 2015. 9. Fazel S, Wolf A, Chang Z, et al. Depression and violence: a Swedish population study. Lancet Psychiatry 2015;2(3):224–32. 10. Fazel S, Wolf A, Palm C, et al. Violent crime, suicide, and premature mortality in patients with schizophrenia and related disorders: a 38-year total population study in Sweden. Lancet Psychiatry 2014;1(1):44–54. 11. Swanson JW, Swartz MS, Van Dorn RA, et al. A national study of violent behavior in persons with schizophrenia. Arch Gen Psychiatry 2006;63(5):490–9. 12. Monahan J, Steadman HJ, Silver E, et al. Rethinking risk assessment: the MacArthur study of mental disorder and violence. New York: Oxford University Press; 2001. 13. Harris MG, Baxter AJ, Reavley N, et al. Gender-related patterns and determinants of recent help-seeking for past-year affective, anxiety and substance use disorder: findings from a national epidemiological survey. Epidemiol Psychiatr Sci 2015;2:1–14. 14. Gannon TA, Rose MR. Offence-related interpretative bias in female child molesters: a preliminary study. Sex Abuse 2009;21:194–207. 15. Sandler JC, Freeman NJ. Female sex offender recidivism: a large-scale empirical analysis. Sex Abuse 2009;21(4):455–73. 16. Gannon TA, Cortoni F. Female sexual offenders: theory, assessment and treatment. Chichester (United Kingdom): John Wiley; 2010. 17. Cortoni F, Hanson RK. A review of the recidivism rates of adult female sexual offenders. Research Report No. R-169. Ottawa (Canada): Correctional Service Canada; 2005. 18. Cortoni F, Hanson RK, Coache ME. The recidivism rates of female sexual offenders are low: a meta-analysis. Sex Abuse 2010;22(4):387–401. 19. Johansson-Love J, Fremouw W. Female sex offenders: a controlled comparison of offender and victim/crime characteristics. J Fam Violence 2009;24:367–76. 20. Miccio-Fonseca LC. Adult and adolescent female sex offenders: experiences compared to other female and male sex offenders. J Psychol Human Sex 2000;11(3):75–88. 21. Elliott IA, Eldridge HJ, Ashfield S, et al. Exploring risk: potential static, dynamic, protective and treatment factors in the clinical histories of female sex offenders. J Fam Violence 2010;25:595–602. 22. Steadman HJ, Osher FC, Robbins PC, et al. Prevalence of serious mental illness among jail inmates. Psychiatr Serv 2009;60:761–5. 23. Fazel S, Sjo¨stedt G, Grann M, et al. Sexual offending in women and psychiatric disorder: a national case-control study. Arch Sex Behav 2010;39(1):161–7.
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24. Gannon TA, Rose MR, Ward T. A descriptive model of the offense process for female sexual offenders. Sex Abuse 2008;20(3):352–74. 25. West SG, Friedhman SH, Kim KD. Women accused of sex offenses: a genderbased comparison. Behav Sci Law 2011;29(5):728–40. 26. Gannon TA, Waugh G, Taylor K, et al. Women who sexually offend display three main offense styles: a re-examination of the descriptive model of female sexual offending. Sex Abuse 2014;26(3):207–24. 27. Lewis CF, Stanley CR. Women accused of sexual offenses. Behav Sci Law 2000; 18(1):73–81. 28. Bierie DM, Davis-Siegel J. Measurement matters comparing old and new definitions of rape in federal statistical reporting. Sex Abuse 2015;27(5):443–59. 29. Federal Bureau of Investigation. Crime in the united states 2013: rape. US Government, US Department of Justice. Available at: https://ucr.fbi.gov/crime-in-the-u.s/ 2013/crime-in-the-u.s.-2013/violent-crime/rape/rapemain_final.pdf. Accessed May 5, 2016. 30. Almond L, McManus MA, Giles S, et al. Female sex offenders: an analysis of crime scene behaviors. J Interpers Violence 2015. [Epub ahead of print]. 31. Mathews R, Matthews J, Speltz K. Female sexual offenders: an exploratory study. Brandon (VT): The Safer Society Press; 1989. 32. Vandiver DM, Kercher G. Offender and victim characteristics of registered female sexual offenders in Texas: a proposed typology of female sexual offenders. Sex Abuse 2004;16(2):121–37. 33. Fedoroff PJ, Fishell A, Fedoroff B. A case series of women evaluated for paraphilic sexual disorders. Can J Hum Sex 1999;8(2):127–40. 34. Greenfeld LA, Snell T. Women offenders. Bureau of Justice Statistics Special Report, Office of Justice Programs. US Department of Justice; 2000. 35. Friedman SH. Realistic consideration of women and violence is critical. J Am Acad Psychiatry Law 2015;43(3):273–6. 36. Friedman SH, Loue S, Heaphy E, et al. Intimate partner violence perpetrated by and against Puerto Rican women with severe mental illness. Community Ment Health J 2011;47:156–63. 37. Buttell FP, Carney MM. Women who perpetrate relationship violence: moving beyond political correctness. New York: Hawthorn Press; 2005. 38. Friedman SH, Loue S. Incidence and prevalence of intimate partner violence by and against women with severe mental illness: a review. J Womens Health 2007; 16:471–80. 39. Straus MA. Blaming the messenger for the bad news about partner violence by women: the methodological, theoretical, and value basis of the purported invalidity of the conflict tactics scales. Behav Sci Law 2012;30:538–56. 40. Catalanos S. Intimate partner violence: attributes of victimization. Bureau of Justice Statistics, Office of Justice Programs. US Department of Justice; 2013. 41. Friedman SH, Stankowski J, Loue S. Intimate partner violence and the clinician. In: Simon RI, Tardiff KT, editors. Textbook of Violence Assessment and Management. Arlington (TX): American Psychiatric Publishing; 2008. p. 483–500. 42. Friedman SH, Cavney J, Resnick PJ. Child murder by parents and evolutionary psychology. Psychiatr Clin North Am 2012a;35(4):781–95. 43. Friedman SH, Resnick PJ. Child murder by mothers: patterns and prevention. World Psychiatry 2007;6(3):137–41. 44. Friedman SH, Hrouda D, Holden C, et al. Child murder committed by severely mentally ill mothers: an examination of mothers found not guilty by reason of insanity. J Forensic Sci 2005b;50(6):1466–71.
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45. Friedman SH, Cavney J, Resnick P. Mothers who kill: evolutionary underpinning and law. Behav Sci Law 2012b;30:585–97. 46. Friedman SH, Sorrentino R, Stankowski JE, et al. Psychiatrists’ awareness of maternal filicidal thoughts. Compr Psychiatry 2008;49(1):106–10.