Trauma in Female Forensic Psychiatric Patients: A Mixed-Method Study into the Clinical Practice of Trauma-Focused Treatment

Abstract

Research shows that victimization rates in forensic mental health care are high for both female and male patients. However, gender differences have been found in types and patterns of victimization (more sexual abuse and more complex trauma for women), cognitive appraisal, and response to traumatic events. Gender-responsive treatments focusing on trauma have been designed to adhere to these gender differences; however, despite promising research results, these interventions are yet to be introduced in many settings. This study examined how trauma is addressed in current clinical practice in Dutch forensic mental health care, whether professionals are knowledgeable of gender differences in trauma, and how gender-responsive factors such as self-esteem, self-efficacy, social relations, and coping skills are considered in treatment for female patients. We used a mixed-method design consisting of an online survey and 33 semi-structured interviews with professionals and patients. The results suggested that Dutch forensic mental health care could address trauma more structurally, and professionals could be more aware of gender differences and gender-responsive factors. Early start of trauma treatment was deemed important but was not current practice according to patients. Based on this study, guidelines were developed for gender-responsive, trauma-informed work in forensic mental health care.

1. Introduction

Trauma history is significantly more prevalent and complex in justice-involved women compared to their male counterparts and has been identified as an important explanatory factor for offending behavior (e.g., Brown and Gelsthorpe 2022; Karlsson and Zielinski 2020; Komarovskaya et al. 2011). To illustrate, in a Dutch multicenter study of 218 female and 218 matched male forensic psychiatric patients, it was found that women, compared to their male counterparts, had experienced more trauma during both childhood (73% versus 63%) and adulthood (55% versus 17%; Bohle and de Vogel 2017). Women were more often exposed to a combination of emotional, physical, and sexual abuse during childhood, and they more often experienced victimization both in childhood and adulthood. Not only is a history of trauma more prevalent and complex in women than in men but gender differences have been found with respect to the response to traumatic experiences. Insights from gender psychology show that compared to men, women report more intense feelings of threat and loss associated with trauma (Olff et al. 2007; Olff 2017; Pantalone et al. 2020) and that they are more susceptible to developing post-traumatic stress disorder (PTSD) following exposure to a potentially traumatic event (Valdez and Lilly 2014). The same has been found to apply to justice-involved women (e.g., Komarovskaya et al. 2011). Hence, trauma is an important factor to address to help justice-involved women recover and prevent recidivism and relapse into, for instance, substance abuse.

Trauma is defined as an event or circumstance resulting in physical harm, emotional harm, and/or life-threatening harm (SAMHSA 2014). This may also include traumatic events like accidents or disasters; however, in forensic mental health care, this usually includes victimization, like physical abuse, sexual abuse, or emotional abuse or neglect. Distinguishing between trauma-focused treatment and trauma-informed care is important here. Trauma-focused treatment is a form of therapy specifically designed to help individuals process and heal from traumatic experiences. It aims to address the emotional, psychological, and sometimes physical effects of traumas experienced. Trauma-informed care is a more general model in which trauma awareness is the core principle, with an emphasis on safety, providing sufficient choices, good collaboration and connection, working on strengths, and building skills (Covington and Bloom 2007). Trauma-informed care has five core principles: (1) safety; (2) trustworthiness; (3) choice; (4) collaboration; and (5) empowerment (SAMHSA 2014). Although trauma-informed care and trauma-focused treatment interventions are also crucial for men, it is suggested that they could be provided in a different way and with somewhat different goals. For traumatized men, for example, it has been suggested that they would benefit the most from training in emotion and behavior regulation and social skills development (Topitzes et al. 2012).

Research over the past twenty years has indicated that there are several aspects that are of particular importance to address in the treatment of traumatized women, for instance, self-esteem, self-efficacy, coping skills, and social relationships (see for a more elaborate discussion of the literature Depla 2021). Addressing self-esteem during treatment is important as research has indicated that traumatic experiences lead to lower self-esteem in women (Salina et al. 2017; Soler et al. 2013), and lower self-esteem is associated with more externalizing problems, higher risks of recidivism, and more PTSD symptoms (Salina et al. 2017; Salisbury et al. 2009; Soler et al. 2013; Yang et al. 2015). Self-efficacy is the individual’s subjective appraisal of the ability to cope with stressful situations and is strongly related to self-esteem. Low self-esteem appears to decrease one’s belief that one can cope with the situation, and such a decrease in self-efficacy is related to an increase in PTSD symptoms (Dutton 2009). Another factor that is recognized as important for gender-responsive trauma-focused intervention is the development of new coping skills. In general, women are more likely to use emotional and avoidant coping styles (Matud 2004; Olff et al. 2007). Using these coping styles is problematic, as they are seen as less effective than problem-focused coping styles and are associated with negative outcomes, including psychological distress and PTSD symptoms. For example, Najdowski and Ullman (2009) examined the association between adult sexual abuse, coping skills, and PTSD symptoms in a sample of women who experienced adult sexual abuse. Their results indicated that maladaptive coping strategies, including self-distraction, denial, and behavioral disengagement, were mediators between adult sexual abuse and PTSD symptoms. More recently, it has been shown that maladaptive coping also serves as a mediator for other victimization forms. Specifically, it was found that maladaptive coping functions as a mediator between the association of various forms of victimization and psychological distress, including PTSD symptoms (Dishon-Brown et al. 2021). Another aspect that is considered to be important for gender-responsive, trauma-focused interventions concerns women’s social relationships. Social support is an important risk and protective factor against (violent) criminal behavior for all patients (Yang et al. 2015). For females, social relationships appear to be even more important compared to male patients (Salina et al. 2017). This is explained via the Relational Theory, which states that women’s identity, self-worth, and sense of empowerment are defined by the quality of their relationships with others (Bloom et al. 2003; Salisbury et al. 2009). Especially in traumatized women, the quality of these relationships appears to be quite poor. Research shows that women who have experienced trauma have more often low levels of (perceived) social support than women without any traumatic experiences. These lower levels of social support are then, in turn, associated with adverse outcomes such as more PTSD symptoms and increased levels of psychological distress (Dishon-Brown et al. 2021; Hill et al. 2010; Stevens et al. 2013; Vranceanu et al. 2007). Concluding, self-esteem, self-efficacy, coping, and social support are factors that are considered to be of particular importance for traumatized justice-involved women and should be targeted in forensic treatment for women.

There are multiple treatment programs focusing on trauma that have demonstrated empirical support for different populations, including justice-involved people. Examples of treatment types or programs with solid empirical backup are Eye Movement Desensitization and Reprocessing (EMDR), exposure therapy, Cognitive Processing Therapy (CPT; see, for instance, Asmundson et al. 2019), and Seeking Safety (Najavits 2002). Only a few programs have been developed or adapted specifically for justice-involved women, for example, Beyond Trauma and Beyond Violence (Covington 2003, 2013) and Seeking Safety (Najavits 2002). These so-called gender-responsive programs usually have a strong focus on trauma and are most often used for substance-abusing women in prison settings and often given by peers (experienced and trained prisoners). It is important to define the term gender-responsive here, as well as sex and gender. The term sex refers to the biological aspects of being female or male, whereas the term gender includes psychological, social, and cultural aspects associated with the biological aspects (for a discussion, see Javdani et al. 2011). Gender-responsive means that gender differences are taken into account as much as possible. These gender-responsive programs focus on recovery from trauma and increasing coping skills to prevent revictimization, for instance, by learning how to set boundaries.

So far, research has yielded promising results for gender-responsive programs in general, that is, a reduction in mental health problems, relapses in substance abuse, and offending behavior (Agarwal and Draheim 2024; Edwards et al. 2022; Van Voorhis 2022). Henderson and Stenfert Kroese (2020) conducted a systematic literature search of group interventions for women in correctional institutions focusing on trauma and substance abuse and found 13 studies of sufficient quality that showed overall positive results, namely, a reduction in symptoms of PTSD and substance abuse. No study has shown a negative effect in terms of worsening symptoms. Seeking Safety was the most studied program with positive results. However, the authors did note that, so far, few studies have been conducted with control groups and recommend more research, especially randomized controlled trials with standardized measurements. They also recommend looking at subgroups of women, for example, divided by type of substance abuse or type of offense. Another recent review found 12 studies of treatment programs after discharge from incarceration for women, all from North America. These showed that five programs had significant reductions in recidivism, and one had significant reductions in substance use (Edwards et al. 2022). Gender-responsive programs focusing on trauma and mental health problems/addiction issues showed the best results. This article further emphasized the importance of tailored care and continuity of care after discharge. Incidentally, there was some overlap between the reviews and the focus of the programs studied (particularly trauma and substance use); however, the focus of the reviews was clearly different: group interventions within institutions (Henderson and Stenfert Kroese 2020) and (individual) programs after discharge or during the resocialization phase (Edwards et al. 2022). It should be noted that most of the studies have been conducted in prison settings and with substance-abusing female prisoners. Research into these programs in forensic mental health settings is scarce.

In a recent overview of gender-responsive programs, Van Voorhis (2022) concluded that the knowledge from empirical studies has been slow to be implemented in daily practice. Questions arise if professionals working in the forensic field have sufficient knowledge about (gender differences in) trauma and know how to address these in daily practice.

The Present Study

The present study aimed to examine the extent to which gender-responsive factors are included in current treatment practices in Dutch forensic mental health care. We examined how trauma is addressed in treatment programs in these settings and whether professionals are aware of gender differences in trauma prevalence, the cognitive appraisal of, and the response to a traumatic event. Furthermore, we examined the extent to which the gender-responsive factors, as recognized by multiple scholars, like self-esteem, self-efficacy, coping skills, and social relationships, are included in current (trauma) interventions for (female) patients.

Gaining more knowledge about trauma-focused interventions and the role of gender-responsive factors is important as it may help to implement trauma-focused interventions and improve treatment by better addressing the needs of female patients. Improving the efficiency of trauma-focused interventions may lead to a decrease in PTSD symptoms and psychological distress, which may reduce the risk of recidivism and help prevent the intergenerational transfer of criminal behavior (Savage et al. 2019).

2. Materials and Methods

This study is part of a larger Dutch national project that aims to gain insight into the challenges experienced in the treatment of female forensic patients and to develop guidelines for gender-responsive work in forensic mental health care (de Vogel et al. 2025). It should be noted that in the Netherlands, women are admitted to gender-mixed settings, and on gender-mixed units, there are no specific forensic mental health settings or units for women only. The research design consisted of an online survey and semi-structured interviews with patients and professionals.

2.1. Procedure

Survey. The data for this study were collected between April and August 2021. The data collection started by distributing the survey aimed to map the knowledge and experiences of professionals working in forensic mental health care regarding the treatment of women in (mixed) forensic care facilities. The participants were recruited using snowball sampling. The survey was sent to all members of the research project, who were all working in one of the participating hospitals of the overall research project (see for more information de Vogel et al. 2025). They distributed the survey within their forensic mental health care settings, for example, by posting it on the local intranet. Furthermore, the survey was distributed on an online community platform for Dutch forensic mental health care professionals and via social media such as LinkedIn.

Semi-structured interviews. In the next phase, we conducted interviews with the aim of deepening the understanding of the results of the survey and recording the personal experiences of both professionals and female and male patients. For the professionals, we used a purposive cell sampling strategy. Professionals were initially recruited via the online survey, where they could leave their names and email addresses in a separate part of the survey if they wanted to participate in the interviews. It was important to have a representative group of professionals for the interviews. Therefore, we selected professionals from various settings and professions from this list, such as sociotherapists, psychotherapists, social workers, vocational therapists, and psychiatric nurses. Next to these professionals, we recruited some professionals whose profession was missing from the list, for example, a psychiatrist. The interviews were semi-structured, and a topic list was created based on the literature and results of the survey. The interviews were held by two researchers, if possible, in an offline setting. Interviews took place online in the case of a long distance between the interviewers and the interviewee or because of COVID-19 restrictions during that period. Of the 22 interviews with professionals, 15 were offline, four interviews were fully online, and three interviews were partly online, meaning that at least one interviewer was physically present with the interviewee, whereas the other joined the interview via telephone. Before the start of the interview, an informed consent form was provided for the participants. All participants agreed to audiotape the interview, and a verbatim transcript was made for all interviews. The interviews were all completed and lasted, on average, 50–70 min and were all held in one session.

Forensic psychiatric patients were recruited via treatment staff from two participating forensic hospitals. It was important that patients were willing and fit to participate. They were informed that they could stop the interview at any point without any reason or consequences for their treatment. All patients provided informed consent and agreed to audiotape the interview, and verbatim transcripts were made for all interviews. All researchers worked in the forensic hospital and remained in close contact with the treatment team to ensure that the patients were fit and stable enough, also after the interview. We aimed to interview mostly female patients but also some male patients to learn from their experiences of being admitted to gender-mixed hospitals. The interviews with eight female and three male patients lasted 20 min on average and were conducted in one session in the forensic setting in a private office. In four cases, a treatment supervisor joined the interview. They gave limited input themselves but sometimes helped to clarify things the participant said. Ethical approval for this study was obtained from the internal ethics committee of the Van der Hoeven Kliniek.

2.2. Materials

The survey, called Women in Forensic Mental Health Care, was conducted using Qualtrics XM Platform 2021 software. The survey consisted of a total of 49 questions, varying from statements that asked for ratings (0–100), correct and incorrect statements, and closed and open questions. The survey was divided into four sections: demographic questions (gender, age, education level, years of work experience, current work setting, and the participant’s professional role), questions related to trauma, questions related to gender-mixed psychiatric wards, and questions about important themes for women in forensic mental health care. For the present study, only the demographic questions and questions related to trauma were used (see for more information about the other results de Vogel et al. 2025). The trauma-related questions are shown in

Table 1. Trauma-related questions in the survey.

1. Is trauma an important risk factor that should be taken into account in the treatment (coded on a 0 (not important at all)–100 (very important) scale)?

2. Which trauma interventions are provided in your setting?

3. When is the best time to start with trauma treatment? 4. To what extent, in your opinion, are current trauma interventions effective for female patients compared to male patients?

5. To what extent do you feel attention is paid to the concept of self-efficacy in the treatment in female patients? 6. To what extent do you feel attention is paid to the concept of self-esteem in the treatment in female patients? 7. To what extent do you feel attention is paid to problem-focused coping in the treatment in female patients? 8. To what extent do you feel attention is paid to improving social relationships in the treatment in female patients? 9. Do you have any tips around trauma interventions for female patients? 10. Statements (answer: true or not true): a. Prevalence of sexual abuse is higher in female patients compared to male patients b. More women than men have been victims of physical or emotional violence/neglect in their childhood. c. Women generally experience more stress during a traumatic event than men. d. Male and female patients both use negative coping styles after experiencing a traumatic event

. For several of the questions, the participants could give an explanation in an open-answer field. The research team formulated these questions based on scientific literature focusing on trauma, trauma-focused interventions, and gender differences in trauma (e.g., Bohle and de Vogel 2017; Brown and Gelsthorpe 2022; Covington and Bloom 2007).

2.3. Participants

Survey. The sample consisted of 295 participants, of whom 70 (23.7%) were male, 224 were female (75.9%), and one identified as non-binary. The participants ranged in age from 21 to 71 years (M = 40.3, SD = 11.4). The majority of participants (n = 192, 65.1%) worked in a forensic inpatient setting, while the rest worked in an outpatient forensic setting or probation service (n = 103, 34.9%). All participants were professionals, and most of them worked directly with patients or clients, such as sociotherapists in forensic hospitals (n = 74, 25.1%), psychologists (n = 77, 26.1%), probation officers (n = 36, 12.2%), nurses (n = 27, 9.2%), art or vocational therapists (n = 18, 6.1%), psychiatrists (n = 8, 2.7%), and other professionals (n = 55, 18.6%). About half of the participants (n = 146, 49.5%) had more than ten years of work experience in forensic mental health care, 43 (14.6%) had between five and ten years, 62 (21.0%) had between two and five years, and 44 (14.9%) had less than two years.

Semi-structured interviews. Twenty-two interviews were held with forensic mental health care professionals and eleven with forensic patients. The professionals were 12 women and 10 men, of whom 21 worked directly with male and female forensic psychiatric patients from 11 different forensic settings and with different professions (see

Table 2. Background characteristics of the interviewed professionals.

Number	Gender	Profession	Setting
1	Female	Probation officer	Probation services
2	Male	Social worker	Inpatient forensic
3	Female	Probation officer	Probation services
4	Male	Assessment coordinator	Dutch Institute for Forensic Psychiatry and Psychology
5	Female	Health care psychologist	Inpatient forensic
6	Male	Sociotherapist	Inpatient forensic
7	Male	Clinical psychologist	Inpatient forensic
8	Female	Clinical psychologist	Inpatient forensic
9	Female	Arts therapist	Inpatient forensic
10	Male	Sociotherapist	Inpatient forensic
11	Female	Health care psychologist	Inpatient forensic
12	Male	Arts therapist	Inpatient forensic
13	Female	Clinical psychologist	Addiction care
14	Female	Arts therapist	Inpatient forensic
15	Male	Sociotherapist	Inpatient forensic
16	Male	Clinical psychologist	Inpatient forensic
17	Female	Health care psychologist	Inpatient forensic
18	Female	Applied psychologist	Inpatient forensic
19	Male	Health care psychologist	Inpatient forensic
20	Male	Psychiatrist	Inpatient forensic
21	Female	Sociotherapist	Addiction care
22	Female	Clinical psychologist	Inpatient forensic

). Eight female forensic psychiatric patients and three male patients from two gender-mixed hospitals were interviewed regarding their experiences with trauma treatment (see

Table 3. Background characteristics of the interviewed patients.

Number	Gender	Setting
1	Female	Inpatient forensic
2	Female	Inpatient forensic
3	Female	Inpatient forensic
4	Female	Inpatient forensic
5	Male	Inpatient forensic
6	Female	Inpatient forensic
7	Female	Inpatient forensic
8	Male	Inpatient forensic
9	Male	Inpatient forensic
10	Female	Inpatient forensic
11	Female	Inpatient forensic
12	Female	Inpatient forensic

).

2.4. Analysis

For analyzing the online survey responses, we conducted descriptive analyses using SPSS Version 27.0. To analyze the semi-structured interviews, we used a Grounded Theory approach (Boeije 2010). This approach was deemed appropriate as the semi-structured interviews focused on experiences with trauma-focused interventions. The analysis started by creating a verbatim transcript for every interview. After producing this transcript, data analysis was conducted in three steps: open coding, axial coding, and the creation of a code tree. During these phases, consensus meetings were held with two researchers and one supervisor. In these consensus meetings, the researchers discussed which fragments were labeled and which code was appropriate. In this way, coding consistency between the research members was maximized, and researcher bias was minimized (Hill et al. 1997). Overall, there were 15 consensus meetings, and there was a good consensus among the researchers regarding the codes. The level of saturation was discussed, and after 18 interviews with professionals and 11 interviews with patients, it was determined that saturation was achieved as no new themes emerged. This is in accordance with the literature, as saturation is usually expected to be achieved with a sample size of between eight and fifteen participants (Hill et al. 1997). However, we had already scheduled four more interviews with professionals and wanted to maintain our commitment to them. Data were analyzed using ATLAS.ti version 9.

3. Results

3.1. Survey

In total, 295 participants completed the online survey. First, participants could indicate the extent to which they agreed to the following statement: ‘Trauma is an important risk factor that should be considered during treatment’ on a scale from not important at all (0) to very important (100). On average, participants agreed to 85.7 (SD = 13.4) with this statement. Next, participants were asked which trauma-focused therapies were offered in their forensic mental health care institute. Eye-Movement Desensitization and Reprocessing (EMDR) was mentioned most often (103), followed by exposure-based therapies, such as narrative exposure, imaginal exposure, imagery rescripting, introspective exposure (29), and creative therapy, such as psychomotor therapy, music therapy, and art therapy (27), psychotherapy (15), cognitive therapy (14), and schema therapy (13).

Table 4. Survey responses when trauma treatment is indicated.

When to Start with Trauma Treatment?	N (%)
Patient had experienced a traumatic event	97 (32.9)
Trauma event was linked to the offense pattern of the patient	173 (58.6)
Symptoms related to PTSD are observed or reported by the patient	156 (52.9)
Solely when a patient is diagnosed with PTSD	15 (5.1)

Note: It was possible for participants to provide more answers.

shows the responses to the question of when to start with a trauma-focused intervention. In the open text box, 30 participants mentioned other reasons for starting a trauma-focused intervention, for instance, when patients express a desire for trauma treatment or when symptoms related to a trauma event hamper forensic treatment.

The next question of the survey asked about the experience of professionals regarding gender differences in the efficacy of trauma-focused interventions in forensic care, showing that the majority of participants believed that interventions are just as effective for female patients as for male patients (see

Table 5. Survey responses to gender differences in the effectiveness of trauma treatment.

The Present Trauma-Focused Interventions Are…	N (%)
Just as effective for female patients as for male patients	250 (84.7)
More effective for female patients compared to male patients	19 (6.4)
More effective for male patients compared to female patients	26 (8.8)

).

The survey included statements about gender differences in trauma that could be answered correctly or incorrectly. The first statement posed that the prevalence of sexual abuse in female patients is higher than that in male patients (true). On average, 60.5% of participants answered this question correctly. The second statement, which declared that women were more often victims of physical or emotional abuse or neglect during childhood than were men (not true), was answered correctly by 80.6% of the participants. The third statement posed that women, in general, experience more stress after a trauma event than men (true) and was answered correctly by 31.3%.

Finally, participants were asked about the amount of attention paid to the four gender-responsive factors during the treatment of female forensic patients. The scores could vary from little to no attention (0) to always/attention (100). The scores show that most attention was paid to training problem-focused coping (M = 72.9, SD = 18.9), followed by self-esteem (M = 66.7, SD = 17.5) and improving social relationships among women (M = 63.3, SD = 20.7). The least attention was given to self-efficacy (M = 55.2, SD = 21.0).

3.2. Semi-Structured Interviews

Interviews were held with 22 professionals and 11 patients. Six main themes were identified during the analysis (see

Table 6. Themes.

Themes and Subthemes
1. Importance of trauma for forensic treatment
- Trauma as a risk factor for recidivism
- Trauma as a responsivity factor
2. Current focus on trauma in forensic treatment
3. Start of trauma-focused intervention
- Early start of trauma-focused intervention in treatment
- Presence of trauma-related symptoms
4. Gender differences in trauma
5. Gender-responsive factors
- Self-efficacy and self-esteem
- Coping
- Social relationships
6. Gender-responsive interventions

).

3.2.1. Importance of Trauma for Forensic Treatment

Many professionals consider trauma to be an important risk factor for recidivism, especially if it is left untreated. Professional 3 described this as: “I think that as long as it hasn’t all been processed, well, you see that the moment they are not doing ok, that through this the chance of recidivism increases”. Professionals and patients mentioned several links between trauma and recidivism. First, trauma was seen as a source of offending behavior. More specifically, trauma impacts the personality structure and development of a person, which then influences their behavior. Patient 10 described this as follows:

Trauma disrupted my system. Therefore, I have been acting in a deviant manner; therefore, I have been acting differently. Therefore, I have been acting, maybe in a sick manner.

For others, trauma was seen as a risk factor for recidivism that could increase anxiety and tension in some situations. This anxiety then leads to feelings of unsafety, with aggressive behavior as a potential result. The last link between trauma and recidivism entailed the relationship between trauma, substance abuse, and reoffending behavior.

Well, mostly recidivism in substance abuse. […] Yeah and I think in the sense that it just happens a lot, right. Substance abuse to fill in. […] Well, and at one point, there is no money left, so yeah, you must do something to fill it up.

[Professional 18].

Some professionals had a more nuanced view of whether trauma is a risk factor for recidivism or not. They reported that trauma could be a risk factor for recidivism but does not necessarily have to be. Whether trauma is a risk factor for recidivism depends on the individual and, more specifically, on aspects such as the severity and duration of the trauma and the extent to which the trauma impacts the person nowadays. According to Professional 16, such a nuanced view is important as some patients may use trauma as an easy scapegoat for their offending behavior.

Say, patients are sometimes also inclined to put their trauma forward to explain their behavior. However, one needs to maintain a nuanced view of it. It is not that every offense is necessarily caused by a trauma.

In addition to trauma as a risk factor for recidivism, several professionals have categorized trauma as an important responsivity factor for treatment. Trauma intervenes with forensic treatment, for instance, by impacting coping strategies and emotion regulation, or impairing one’s ability to follow/focus on (psycho)therapy. Professional 17 explained this as follows:

If you have a spider phobia and there is a spider in the room, and in the meantime, someone tries to give you therapy, then you are only focused on the spider. And that is, of course, the same with trauma.

3.2.2. Current Focus on Trauma in Forensic Treatment

Multiple professionals and patients shared the opinion that insufficient attention is currently being paid to trauma and that this should be expanded. Examples of how to pay more attention to these themes were offering trauma-focused interventions at an earlier stage of treatment or offering trauma-focused interventions more often. A possible reason for this lack of focus was that the offered treatment is mostly targeted toward harboring safety and preventing further acting out behavior. Treatment is more focused on the patient’s current behavior, for example, aggression, than the past. Professionals described this as “superficial”, as the underlying causes of this problematic behavior are not sufficiently addressed:

Well, one is mostly focused on right here right now, teaching skills, and there is insufficient attention for the past and influences from the past, trauma, and this being a trigger for offending behavior.

[Professional 5].

Furthermore, Professional 3 indicated: “I think that well, trauma is not always recognized. Other problems are more prominently present, and one pays more attention to them”. Another reason for the lack of attention to trauma is the lack of knowledge regarding this theme. It was indicated that the needed expertise in trauma-focused interventions is currently missing in Dutch forensic mental health care. Professional 11 explained this as follows: “And I think that, from a starting point as treatment supervisors, everyone is sort of a generalist, where we all know a little about trauma. Well, and expertise on trauma should be sort of externally brought in”. Therefore, many treatment supervisors indicated that they would like to pay more attention to trauma and offer more and quicker trauma-focused treatment, but they do not have sufficient knowledge and necessary skills.

3.2.3. Start of Trauma-Focused Intervention

Most professionals indicated that trauma-focused interventions should start as soon as possible because it may diminish the risk of trauma and that, by treating trauma, other symptoms may be reduced. Professional 19, who is also seen as an expert on EMDR, explained it as follows:

Imagine that you have a castle, and within the castle, lays the trauma. And the walls of the castle protect the trauma. From the outside, you see, you see symptoms. For example, emotion regulation problems, addiction to aggression problems, or well, you name it. Imagine that you are treating the outside. Yeah, well then, you are literally treating the outside.

More specifically, trauma-focused interventions should start when trauma symptoms such as nightmares and flashbacks are prominently present and patients have a severe level of suffering from these symptoms. The trauma-focused intervention then starts, irrespective of a possible link between trauma and offending behavior. “I think the moment trauma is prominently present; it is so disrupting for everything else that you get a state-component. I can imagine you first try to reduce the pressure [Professional 7]”.

However, the link between trauma symptoms and offending behavior is not meaningless. From a forensic perspective, trauma-focused intervention has been described as more relevant when there is a link between trauma (symptoms) on the one hand and offending behavior. As Professional 2 explained, examining whether there is a link between the two is, therefore, important:

If trauma plays a major role in the risk of recidivism, one should start with that. If that is the greatest risk for recidivism, you just start with that. Of course, you treat it to prevent recidivism in criminal behavior. If it is clear that this is caused by trauma, start with it.

Despite the opinions of professionals that trauma-focused interventions should start as soon as possible, patients who were interviewed mentioned that they had to wait a long time before starting trauma-focused treatment. Patients mentioned that they experienced long waiting lists before they could start trauma-focused treatment. When asked, most patients waited for up to two years before trauma-focused interventions were started. Patient 10 also indicated that she would have appreciated it if the trauma-focused intervention had started sooner in her treatment:

It started in 2016 or 2017, and I have been admitted here since 2015. […] So, one says 1,5 years. […] Well, I wanted to directly start with it […] So, yeah, it would have been nice if they gave it some priority.

Patient 11 indicated the following when asked why trauma-focused therapy started after two years: “I think there was no time for it [trauma-focused intervention]”. Furthermore, regarding the psychiatric status of the patients when starting the trauma-focused intervention, it was noticeable that all patients were diagnosed with PTSD. All patients also indicated that they experienced trauma-related symptoms in the period before starting the trauma-focused intervention.

3.2.4. Gender Differences in Trauma

According to several professionals, women have experienced more abuse than men. In particular, sexual abuse was frequently associated with abuse in intimate relationships. Professional 2 described: “saying it roughly, I say that trauma is more relational for women. So, domestic violence, rape, incest, those types of things”. On the other hand, men seem to experience more violent traumas outside the domestic realm, for instance, on the streets. It was described that, sometimes, men experience trauma during committing criminal activities themselves, in the criminal milieu. Professional 2 said: “For men, it is more often related to physical violence, such as threatening with weapons, seeing someone get shot, or shooting someone themselves”. Nevertheless, some professionals did not see a significant difference between men and women regarding the type of traumatic event. “Well, almost no [difference in the type of trauma event]. I also see much history of sexual abuse in men. Maltreatment occurs in both men and women. Neglect. Yes [Professional 8]”.

Regarding prevalence rates, some professionals remarked that women in forensic care are, in general, more traumatized than men. Professional 4 was firm and said: “I think if you put 100 women and 100 men next to each other, there will be more traumas in the women group than the men group”. Others were more skeptical about the differences in trauma prevalence between men and women. Women are not necessarily more traumatized, but there is a bias in reporting trauma in women, making it more likely that the prevalence rates for men are underestimated. Professional 5 remarked: “So yes, I do not want to say that women are necessarily more often traumatized than men. That is, I think it is disqualification. I think that you should not underestimate that, especially for men”.

An explanation for this bias could be related to feelings of shame and embarrassment experienced by men. These feelings made it more difficult for them to report trauma. Professional 16, described this as follows: “I think women report trauma quicker than men. For men, shame will play a role in abuse and maltreatment”. Furthermore, the media image of trauma could explain the underestimation of trauma in men. Professional 2 remarked that trauma is generally more associated with women: “For women it is, so to speak, seen as very common that it could be like that [experiencing a trauma]”. In addition to this, Professional 6 also noted: “A woman is still, is more often seen as fragile”. Lastly, professionals may question women more often than men about trauma. Professional 2 described: “I just think that for women, there is a closer eye for it, and it is more often asked and therefore more often reported. But I don’t believe that it occurs less often in men”. Taking this bias into account, many professionals did not see a significant difference in prevalence rates between men and women. Instead, it is said that: “It is more likely 50/50 [Professional 6]”.

Regarding gender differences in the experience of trauma, professionals mentioned that a traumatic event might have a greater impact on women than men. Women were characterized as more emotional and experiencing trauma more intensely. For example, Professional 5 described the difference between women and men as follows: “Yes, meaning that women are more emotional, and it affects them more intensely. […] Well, and men continue easier”. Furthermore, Professional 15 described: “I see women fall apart more. And then I see more consequences for their functioning”. In contrast, men carry on more easily after a traumatic event. Professionals, however, also emphasized that men may find it more difficult to talk about their emotions.

And at the same time, we should not underestimate the impact of some events. And that they [men] may find it more difficult to talk about it. Another possibility may be that men experience more shame, or they tell themselves that they just need to: continue and not, less talk and more action, you know.

[Professional 5].

It has also been mentioned that men do not evaluate a potentially traumatic event as traumatizing. Professional 10 described this accordingly: “And men may label things less as trauma. Well, so they experienced heavy, violent situations, but they don’t see it as traumatic”. Nevertheless, other professionals did not describe any substantial differences between men and women in terms of how they experienced a traumatic event. Instead, Professional 6 remarked: “I think in the mind all traumas are intense”. Some of them, however, described a difference in gender regarding the expression of trauma. Women were more often characterized by internalizing problems, whereas men showed more acting-out behavior as an expression of trauma symptoms. Professional 7 summarized: “Maybe men, I don’t know, are more prone to act out and then put it away. And well, women keep it, in general, more inside”.

3.2.5. Gender-Responsive Factors

Self-esteem and self-efficacy. Professionals found it challenging to distinguish between self-esteem and self-efficacy; therefore, we present the findings in an integrated manner. Various interventions to improve self-esteem and self-efficacy were mentioned. These interventions range from explicit interventions, including psychotherapy, creative therapy, and psychotropic medication. Some of the psychotherapeutic interventions mentioned are similar to trauma-focused interventions, such as schema therapy and a specific form of EMDR called flash-forward. Furthermore, sociotherapists and probation officers named positive stimulation as a more implicit way to improve self-esteem and self-efficacy. Positive stimulation entails giving compliments, generating positive experiences, and supporting patients.

However, these interventions did not differentiate between women and men. Instead, professionals emphasized the importance of focusing on the individual. Nevertheless, some professionals have observed differences in self-esteem between women and men. Women were described as being more vulnerable and fragile, and experiencing more problems with self-esteem and self-efficacy. Professional 4 remarked: “In general, I think that the women we see often have little esteem and self-esteem. Well, and they think very negatively about themselves. […] I noticed that this happens more to women than men”. However, not everyone agreed that self-esteem was more often an issue for women than men. Rather, the expression of a lack of self-esteem differed between the genders. Men would often express their lack of self-esteem by acting out their behavior. Professional 18 remarked: “Men, it is sure that men also have a very negative self-image and are insecure, but they agitate in it differently. Men externalize more often. More often express in the form of aggressive agitation”. Men are also described as pretending to have high self-esteem, for example, by having a narcissistic attitude, while they have little. Professional 21 characterized this as follows: “For men, you see more macho behavior. So yes, it [self-esteem] differs in how it is expressed. But in reality, I don’t know if there are many differences”. In contrast, women would express their lack of confidence more easily and resort to expressions such as self-injurious behavior.

Addressing self-esteem during treatment was recognized as an important element for forensic treatment, or as Professional 2 remarked: “Yes, it is acknowledged that treatment will be more successful whenever someone also believes that it will be successful”. Many professionals agree that self-esteem is sufficiently addressed during treatment. For example, improving self-esteem and self-efficacy are often marked as treatment goals. However, some criticized that self-esteem is often addressed during treatment, and few training situations have been created. Furthermore, teams should be better instructed to address self-esteem.

The patients described several forms of intervention that improved their self-esteem and self-efficacy. Among all interventions, schema therapy was mentioned most often. Other therapies included psychotropic medication, emotion regulation, and support from professionals working in forensic psychiatric wards. The effects of these interventions are mostly positive. For example, Patient 3 described: “I dare doing many more things. I also gave a presentation recently. So, it gets better every day”. Furthermore, several patients reported positive effects after schema therapy: “Schema therapy did that [improving self-esteem] yes. I recognize more things in myself [Patient 11]”. Despite these interventions, some patients remarked that they mostly worked on self-esteem themselves, without much help from professionals. For example, Patient 10 described: “I did a lot of it myself. Again, right now. […] I listen to many podcasts where they give tips or, well, guided meditation”. Furthermore, Patient 10 continued by saying that self-esteem could have been more often and explicitly addressed during treatment: “Well, how do I explain? I miss something about this. That it’s really about self-esteem”.

Coping. A great variety of interventions focused on improving maladaptive coping strategies were mentioned, such as psychotherapy, Competitive Memory Training (COMET), protocols for emotion regulation, schema therapy, and Cognitive Behavioral Therapy. Psychotherapy can take place in either an individual or group format. Second, coping was addressed by the teams working in the psychiatric wards: “Well, you know the socio-therapeutic environment as intervention is, of course, an intervention. How do you deal with each other? What’s happening? That is, of course, one of the ways, like how are you fixing your problems [Professional 1]”. Finally, psychotropic medication was administered to stabilize a psychiatric condition.

In general, the interventions did not differ between the men and women. However, Professional 5 indicated that she adjusted her psychotherapy to women by taking more time to finish some modules:

Well, I think that there are some themes for women, well, that it is just a bit different. Yes, well, you can approach it differently, or you claim more space for it and ask more in detail about it.

Using these different approaches for men and women would fit the gender differences described by professionals. It was described that, in contrast to men, women would use more avoidant coping styles, have more drug abuse, and are more helpless. For men, coping is often described as aggressive and other acting-out behaviors. Professional 5 described these differences as follows:

Well, yes. I think men have more frequent acting-out behavior, and women are more avoidant in their anxiety. For example, consider female shoplifters. They express this in a passive and aggressive manner. […] Well, they steal to get rid of some form of tension. Right, well, men lose tension by slapping others.

However, not everyone agreed with this distinction between men and women. Some professionals have indicated that both female and male forensic patients use maladaptive coping styles, such as avoidance. Professional 6 remarked: “They are all prone to avoid. Are they facing dispute? No, they just call in sick and stay in bed”.

Most professionals agreed that there was sufficient focus on improving coping styles. It was often characterized as one of the core elements of forensic treatment, seeing that maladaptive coping posed a great risk for recidivism: “Well, it [coping] is high on the agenda. Actually, you know, you only get admitted to forensic psychiatry when you commit an offense, of course. […] And that is also a type of coping [Professional 4]”. However, such improvements are always possible. Professional 21 said: “It is always a good idea to receive more training and be more conscious, also for professionals. Also, being aware of all coping styles and how you can influence that on a behavior level”.

Patient 10 described: “The hospital did nothing at all. It was really a no”. The experiences of Patient 6 fit with the previous description: “Well, I did not get, you know, therapy to find good coping. I did it myself”. Nevertheless, some patients described interventions focused on coping, such as discussing issues with a sociotherapist working on their unit.

Social relationships. Professionals described some differences between the social networks of men and women, particularly in terms of size, pro-social elements, network type, and focus on the network. Regarding the size of social relations, professionals indicated that a woman’s network was, in general, larger than a man’s social network. Professional 21 described this by saying: “They [women] always have someone left”. Furthermore, the social network of women has been described as more pro-social and supportive: “Well the network of women is, in terms of percentages, more pro-social, at least there are more pro-social elements present [Professional 20]”. The social networks of women also often included children, whereas they were less present in the networks of men. Professional 11 described the following: “Well, you see quite often when women have children; they are more in contact with them than men. At the same time, you see that these are the factors they are working for”. Lastly, women seem to be more focused on their network than men are. Professional 5 described this as follows:

Yes, I think women have a greater need for more [social network]. You can see that the threshold to include them in the forensic part differs. But, yes, I see that women would like to do it together, in contrast to men.

Although women may have a larger and more pro-social network than men, the networks were still described as limited and consisting of antisocial elements. Many professionals, therefore, remarked that for both men and women, the network often forms a risk factor for recidivism:

Well, the social network is sometimes very problematic, sometimes, it does not exist, sometimes, a social network exists of fellow drug abusers of fellow detainees.

[Professional 18].

Interventions focused on improving patients’ social relationships either focused on restoring the existing pro-social social network or attempting to build a new pro-social network. The existing network could be restored by regaining contact with family and friends and involving them in treatment. Often, systemic therapists, social workers, or network supervisors can help strengthen these networks. To create a new social network, patients are taught social skills, and in a later phase, they can get in contact with a volunteer or join social activities, such as going to church. However, strengthening existing networks and creating new ones can be difficult in forensic mental health care. In the opinion of Professional 21, there is never enough attention to this topic:

It can always be better. […] You sometimes see that you are so engaged in keeping everything on order internally. And then you forget that all those women and men go back to their network. If this remains the same, then nothing really changes. So I think you can never pay too much attention to it.

Some professionals criticized the limited number of systemic therapists and social workers in forensic mental health care: “Just inform on how many systemic therapists are working in forensic psychiatry. That is distressing [Professional 4]”.

In general, the patients agreed that they were sufficiently helped to reconnect and rebuild their networks. Interventions that were named useful included the guidance of network supervisors in reconnecting with family and friends, a ‘buddy’ volunteer, and engaging in activities outside the forensic psychiatric hospital. Patient 3 described that: “The idea is that well, during the unsupervised leave, also outside with activities or a community center, that I meet new people whom I can befriend”. However, some patients experienced difficulties in creating new contacts. Patient 9 said, “It is difficult outside. Most of them are people using drugs”. He would have, therefore, appreciated it if the forensic psychiatric hospital had put more effort into helping him create a new social network.

3.2.6. Gender-Responsive Interventions

Professionals responded positively to the concept of gender-responsive interventions as they believed this could be valuable information that could increase the effectiveness of current interventions. Professional 17 remarked: “I think we never stop learning, and all information that we have on how to fit better and how to make a treatment more effective is just very useful”. Another healthcare psychologist saw gender-responsive interventions as a way of creating peer support among women:

Take the topic of confidence. I can imagine a woman saying: well, I am ugly. And all men will feel the need to say: you are looking great. Then, you are still not getting to the point. Thus, the identifiability between women has a ring to it.

[Professional 11].

In addition to these positive responses, it was often emphasized that forensic treatment should be tailored for each individual patient and their needs. Hence, Professional 15 remarked: “Yes, good idea, but you still need to look at the person because it has to remain bespoke treatments”. Therefore, whether gender-responsive interventions or knowledge are useful depends on the individual. This argument has also often been mentioned by opponents of gender-responsive interventions. Instead of focusing on gender, the individual’s needs should be central. Professional 22, working in a forensic psychiatric hospital, responded as follows:

Ridiculous. […] I always think: every person is different, so some men really want to talk about their emotions, they must otherwise keep doing what they do. So, no, I think you should just connect to the person.

Moreover, two potential problems were mentioned. First, the distinction between ‘women’ vs. ‘men’ may not fit everyone, for instance, transgender people or individuals who identify as non-binary. Secondly, Professional 13 explained not feeling comfortable by excluding a person based on their gender: “Because why wouldn’t there be a man who could profit from female groups and also a woman from men groups”.

Some forms of gender-responsive interventions have already been used by mental health care institutions. For example, Professional 21 worked in an institute that only admits female patients, and during group sessions, ‘female-specific care’ was given: “Well there is a group evening to talk about sexuality and setting limits, and well, those kinds of things. So, female-specific care”. Others implemented gender-responsive interventions by using existing protocols more on women than on men, taking more time to conduct certain protocols when dealing with women, or organizing a women’s group in which themes such as empowerment are discussed.

4. Discussion

This study examined the extent to which gender-responsive factors are considered in current interventions in Dutch forensic mental health care, based on a survey of 295 forensic mental health care professionals and semi-structured interviews with 22 forensic mental health care professionals and 11 female and male forensic patients. The results showed that many forensic mental health care professionals identified trauma as an important factor that should be addressed during forensic treatment. However, there was limited consensus on how trauma should be considered. One group identified trauma as a risk factor for recidivism, whereas others saw trauma mostly as a responsivity factor for treatment. This may indicate that forensic mental health care professionals are becoming increasingly aware of the importance of considering trauma in their treatment plans. Furthermore, identifying trauma as an important factor that should be considered in treatment plans is in line with the contemporary literature on this topic (Asscher et al. 2015; Dishon-Brown et al. 2021; Fitton et al. 2020). Moreover, identifying trauma as a responsivity factor that may hamper effective treatment fits the evidence-based RNR model (Bonta and Andrews 2024). Therefore, the exact classification may not necessarily matter as long as trauma is structurally included in treatment plans (Fritzon et al. 2021).

Regarding the start of the trauma-focused interventions, it became apparent that trauma was often considered in a treatment plan when patients report many trauma symptoms or when there appears to be a link between the trauma and the offending behavior. Moreover, starting under these conditions fits mostly with the rationale of the RNR model. First, by starting a trauma-focused intervention whenever trauma is identified as a risk factor for (re-)offending behavior, one acts in line with the rationale of the Risk principle. Second, one can argue that the responsivity principle is considered when addressing trauma when trauma symptoms are reported by the patient, as focusing on reducing trauma symptoms makes patients more responsive to other types of interventions during forensic treatment.

Furthermore, what is striking about the start of trauma-focused interventions is the incongruity between the wishes of professionals and the patients’ experiences in clinical practice. Many professionals wished to start with trauma-focused intervention as soon as possible during treatment. Nevertheless, patients in the present study experienced long waiting times before the trauma-focused intervention could start, even up to two years. Addressing trauma later in treatment is unfortunate, as it may undermine the efficacy of forensic treatment. Research has shown that PTSD is related to many aspects of (mental) health, such as psychological distress, emotion regulation, and drug abuse (Dishon-Brown et al. 2021; Najdowski and Ullman 2009; Stevens et al. 2013). By addressing these aspects first instead of trauma, one may not get to the ‘core’ of the problem, namely, the trauma.

The results showed that starting trauma-focused interventions in an early phase of forensic treatment remains difficult. Although there is a growing trend to include trauma in treatment plans, a structural approach to address trauma remains sparse. Instead, the results showed a strong emphasis on externalizing behavior and deficits in emotion regulation of patients in Dutch forensic mental health care. Hence, underlying problems related to the etiology of offending behavior, such as trauma and lack of attention. Furthermore, forensic mental health care professionals in the Netherlands appear to have too little knowledge regarding trauma, making it more difficult to recognize trauma symptoms or start a trauma-focused intervention.

Nevertheless, incorporating a structural approach regarding trauma is important as it has positive effects on treatment, such as increasing the efficacy of (trauma-focused) treatment and reducing the risk of recidivism. For instance, trauma-informed care is a framework that structurally addresses trauma. Important principles of trauma-informed care are creating awareness about the prevalence and impact of trauma on individuals, enhancing knowledge about trauma symptoms in professionals and patients, using this knowledge to create policies and practices, and actively avoiding re-traumatization (SAMHSA 2014). Research has shown that trauma-informed care is associated with increased responsivity to trauma-focused interventions and a reduction in the risk of recidivism (Miller and Najavits 2012, see also a recent special issue of International Journal of Forensic Mental Health about trauma-informed care by Jones et al. 2024).

Furthermore, the present study showed that when trauma-focused interventions are included in treatment plans, EMDR is often the premier choice of intervention. The use of such exposure-based therapies, particularly EMDR, has also been associated with a reduction in PTSD symptoms in the non-forensic adolescent population (Chen et al. 2014; McLean et al. 2022). However, in more complex trauma, such as childhood or multiple traumas, EMDR appears to be less effective (Kaminer and Eagle 2017). As many patients are victimized during childhood or have experienced multiple victimizations (Bohle and de Vogel 2017), criticism of professionals that “you cannot EMDR everything away”, seems in line with the current research on the efficacy of EMDR in complex trauma situations. Schema therapy, which was also often mentioned as a trauma-focused intervention in the present study, or the short-term intensive trauma treatment, which is currently being implemented in some forensic psychiatric hospitals in the Netherlands, may be more suitable for these complex trauma cases (Boterhoven de Haan et al. 2019; Peeters et al. 2021; Van Woudenberg et al. 2018; Voorendonk et al. 2020).

In accordance with the literature on victimization among forensic population professionals, the prevalence of sexual abuse was higher in female patients than in male patients (Bohle and de Vogel 2017). Regarding the overall prevalence, professionals were more hesitant to identify gender differences. Instead, they indicated a bias in reporting trauma in women, making it more often underestimated in men. Therefore, in the end, many professionals experienced no significant difference in prevalence rate between female and male patients. At first sight, these results run counter to the literature, indicating that female patients have experienced more victimization than their male counterparts (Bohle and de Vogel 2017; Hill et al. 2014). However, the differences in the results may be partly explained by an underestimation of trauma in men, i.e., that men may be more hesitant to reveal a history of (sexual) abuse than women (Machado et al. 2016). For instance, literature regarding intimate partner violence (IPV) shows that men are less inclined to report trauma because of difficulties in self-identifying as victims and feelings of shame (Machado et al. 2016). Moreover, IPV is subject to stereotypes, making it less likely to be identified by professionals when the victim is male and is seen as more acceptable by society than female victims (Bates et al. 2019). Many studies examine prevalence rates using file information; hence, underestimation may be possible as men may report (IPV) traumas less often and professionals less often notice the trauma.

Similar to the overall prevalence rates, professionals were more hesitant to describe gender differences in the cognitive appraisal of a trauma event. Professionals who reported gender differences described trauma events as more impacting women than men. These results are somewhat in line with research indicating that women experience traumatic events as more distressing and have more intense feelings of fear, horror, and helplessness than men (Olff et al. 2007; Valdez and Lilly 2014). Nevertheless, the outline of professionals focuses more on the behavior of women and men after experiencing trauma, whereas the literature describes an emotional and cognitive process. An explanation for this difference could be the lack of knowledge about the emotional and cognitive differences between women and men after experiencing a traumatic event. Furthermore, focusing on the behavior of patients fits with results demonstrating that Dutch forensic mental health care is mostly focused on behavior and less on underlying problems of offending behavior.

Regarding gender-responsive factors, such as self-esteem, self-efficacy, coping, and social relationships, it became apparent that all factors were, at least to some extent, included in current treatment plans in Dutch forensic mental health care. The inclusion of these factors in treatment plans for women corresponds to gender-responsive interventions, such as Beyond Trauma, as they emphasize enhancing self-esteem, self-efficacy, and strengthening social support (Covington 2003, 2013). However, it differed among the factors of how they were included in the treatment. Professionals often saw coping and social relationships as core themes of treatment, whereas self-esteem and self-efficacy were less often explicitly addressed during treatment. However, these results are in contrast with the experiences of patients. While patients could name several interventions for self-esteem, self-efficacy, and social relationships, naming coping interventions was more difficult. A possible explanation for this gap is that patients may not always recognize coping interventions because interventions that address coping serve various goals, such as schema therapy.

Furthermore, it became clear that almost no professional differentiated between female and male patients when targeting these specific factors, which means that women and men received, in principle, the same interventions. The lack of differentiation based on gender contrasts with research that shows that women and men may have different needs (Dishon-Brown et al. 2021; Najdowski and Ullman 2009; Salina et al. 2017; Stevens et al. 2013). In addition, these differences in needs have been recognized by many professionals. They experienced differences between women and men regarding self-esteem, self-efficacy, social relationships, and coping to a lesser extent. The reason for the absence of a gender-responsive approach may be a lack of awareness about gender differences in these factors and the possibility of gender-responsive treatment.

In general, professionals responded positively to the knowledge of gender-responsive interventions. This was mostly seen as valuable information that could be used during treatment. Still, some professionals found gender-responsive treatments old-fashioned, as they use traditional gender constructs. Professionals indicated that the emphasis should always be on the individual and their need for treatment. This is in line with the literature that shows that gender-responsive interventions are most effective when the patient displays the risk factors addressed in the intervention (Day et al. 2015).

4.1. Limitations

The present study has several limitations. First, no definition of trauma was provided in the survey or during semi-structured interviews. Consequently, it may have been possible for the participants to use different definitions of trauma. The lack of a strict definition may be especially relevant for situations in which trauma is related to attachment problems. Some professionals explicitly declared that they included pedagogical neglect as part of trauma, whereas others were less clear about this. Nevertheless, during the interviews, participants were asked about the differences in the types of trauma events between women and men. In all cases, the same types of events were named, such as sexual or physical abuse, indicating that many professionals also agreed to a substantial level on what to include in trauma. Furthermore, although we included definitions of, for instance, self-efficacy, in the survey, we cannot be sure if all participants had the same understanding of these concepts. During the interviews, we experienced that professionals had difficulty distinguishing between self-esteem and self-efficacy.

A second limitation is the potential bias and social desirability in the answers in the survey, as these are self-reported. More generally, it is possible that there was bias in the respondents of both the survey and the interviews. We recruited broadly, but it cannot be ruled out that especially professionals participated who already had a clear opinion or specific experiences in working with women or in a gender-mixed setting. A third limitation of the present study is the limited input of patients compared to professionals. Eleven patients were interviewed from only two forensic mental health care institutes. Several of these patients had no experience with trauma-focused interventions, making their input for the present study minimal. The input of these patients consisted mostly of their experiences with gender-mixed treatment. Furthermore, when asked about interventions focused on self-esteem, self-efficacy, coping, and social relationships, many patients had difficulty describing interventions for coping and self-esteem. A treatment supervisor who joined one of the interviews disclosed to the researchers that the patient received treatment focused on these factors; however, the patient did not recognize this. It may be possible that this is similar for more patients, meaning that treatment was focused on these factors, but they did not notice this or were not able to reflect upon it because of their current mental health state.

Another limitation of the present study is related to the representativeness of the survey. The survey has been distributed to many forensic mental health care institutes and via social media. As so many people have been approached for the survey, it is difficult to determine how representative the survey participants are of Dutch forensic mental health care in general. Finally, it should be noted that during the interviews, the focus of the topics shifted somewhat. As a result, the findings presented in this article do not always fully align with the initial aims of this study.

4.2. Implications for Clinical Practice

The present study shows that the inclusion of trauma in treatment plans and programs in Dutch forensic mental health care should be improved. We recommend strategies that focus on strengths-based approaches and actively support post-traumatic growth. The introduction of trauma-informed care focused on enhancing knowledge regarding trauma impact, prevalence, and symptoms, and including this knowledge in policies, procedures, and practices is therefore also strongly recommended (Levenson and Willis 2019; SAMHSA 2014; Simjouw et al. 2024). By implementing trauma-informed care, mental health care professionals can be trained and become more aware of trauma, its impact, and its symptoms and gain more expertise on this topic. Such an increase in awareness of trauma and expertise may help to prevent revictimization and to start trauma-focused interventions more often and at an earlier stage of forensic treatment.

Furthermore, more awareness can be created regarding gender differences in trauma, as the present study showed that knowledge regarding gender differences in trauma is still limited. Especially knowledge regarding gender differences after experiencing a trauma event appears to be scarce. More awareness of these topics is important, as it allows mental health care professionals the opportunity to incorporate this knowledge into their work, for instance, by recognizing gender-specific trauma symptoms. More awareness is also necessary regarding gender-responsive factors, such as self-esteem, self-efficacy, coping, and social relationships. Currently, these factors are included in treatment plans in Dutch forensic mental health care settings, but no distinction is made between women and men, although research has shown that there are gender differences and that a tailored approach could be beneficial for both genders. Forensic mental health care professionals should be more aware of these gender differences to include this knowledge in treatment, for example, by addressing these factors differently for women and men.

Based on the current study and the larger project on gender-responsive work, a guide has been developed (reviewed de Vogel et al. 2025 that is currently being implemented in gender-mixed forensic psychiatric hospitals in the Netherlands. This guide formulates trauma-informed care and relational working as a basis and provides specific guidelines for gender-sensitive risk assessment and gender-responsive and gender-specific policies and treatment. Furthermore, an awareness campaign has been started by the Dutch Expertise Center Forensic Psychiatry to help the field gain more knowledge about gender differences and implement gender-responsive strategies (see https://efp.nl/projecten/gendersensitief-behandelen, URL accessed on 15 December 2024).

4.3. Implications for Future Research

Future studies related to trauma should examine the extent to which trauma-focused interventions such as EMDR are effective in forensic populations. In the present study, EMDR was one of the most frequently chosen interventions for trauma; however, research on the efficacy of EMDR in forensic populations is limited. Furthermore, in more complex cases of trauma, EMDR appears to be less effective in comparison to less complex single cases of trauma. Research on the efficacy of EMDR in forensic settings using a sample of both men and women could contribute to the implementation of gender-responsive evidence-based interventions in forensic care.

Moreover, future studies should focus on the efficacy of gender-responsive interventions in Dutch forensic mental health care. None of the interviewed professionals implemented any form of gender-responsive interventions. Gender-responsive interventions are, in general, valuable information that could increase the efficacy of current treatments. However, the implementation of current gender-responsive interventions is not that easy. Many gender-responsive programs have been designed for justice-involved women in North America, which differ from Dutch forensic mental health care. Therefore, future studies should examine how gender-responsive interventions can be introduced and investigated in the Netherlands and other countries.