Gender Considerations in

Violence
a, b c
Renee Sorrentino, MD *, Susan Hatters Friedman, MD , Ryan Hall, MD

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 incar-
ceration 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 de-
creases in the setting of mental illness.2 Understanding the gender differences and
similarities in violent behaviors helps to establish accurate risk assessment and treat-
ment. 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 Sup-
port Building, Room 12-003, Grafton, Auckland, New Zealand; c Department of Psychiatry, Uni-
versity 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: rsorrentino@partners.org

Psychiatr Clin N Am - (2016) -–-

http://dx.doi.org/10.1016/j.psc.2016.07.002 psych.theclinics.com
0193-953X/16/ª 2016 Elsevier Inc. All rights reserved.
2 Sorrentino et al

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 primar-
ily 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 mea-
sure, 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 drink-
ing, and past criminal justice involvement.4
An additional confounding variable for violence risk assessment is mental health his-
tory. 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 3

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 dis-
orders (eg, delusional disorder, schizoaffective disorder, unspecified psychosis) in a
Swedish population over age 38. Again the conclusion was that a mental health diag-
nosis increased the risk for violence for both men and women, especially for individ-
uals 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 dis-
orders and 10.7% of the men committed a violent crime within 5 years of being diag-
nosed. 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 cor-
relation 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 col-
leagues9,10 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 individ-
uals 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 treat-
ment 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 treat-
ment 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
4 Sorrentino et al

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 victim-
ization 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 of-
fenders.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 stereo-
types 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 offend-
ing, 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 tradi-
tional preconception of women as nonviolent nurturers. Biased physicians and police
officers do not detect sexual offenses perpetrated by women. As a result, those pro-
fessions, 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 disor-
ders. Female sex offenders report high rates of mood, anxiety, and substance use dis-
orders.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 differ-
ence in psychiatric symptoms or diagnoses when female sex offenders were
compared with male offenders. Compared with the general population, female sex of-
fenders 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 counter-
parts, 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 bio-
logical 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 5

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 recid-
ivism 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 male-
perpetrated rapes.28 Although studies have shown that women rarely engage in
rape behavior, the prevalence may be obscured by the gender bias in sexual offend-
ing. For example, before 2012, the FBI defined rape as the “carnal knowledge of a fe-
male 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, regard-
less 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 perpe-
trator 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 au-
thorities 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 main-
tain the relationship. The predisposed group refers to women who are predisposed to
sexual offending because of a history of incest, deviant sexual fantasies, and psycho-
logical difficulties. The predisposed female offenders were more likely to abuse their
own children or intrafamilial victims. The last group described by Mathews and col-
leagues31 is teacher/lover. Teacher/lover offenders are often in dysfunctional peer re-
lationships 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 catego-
rized female sex offenders into 6 groups based on the demographics of victim char-
acteristics and criminal histories. The 6 categories were dominant woman abuse
(adult woman abusing adult male), experimented/exploiter (younger offender exploit-
ing a child under her care), babysitter abuse (younger boy assaulted by unrelated fe-
male), 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
6 Sorrentino et al

samples. Federoff and colleagues33 reviewed 15 female sex offenders using Diag-
nostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for para-
philias, 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 vali-
dated risk assessment instruments for women. The current appraisal of risk to recidi-
vate 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 alterna-
tively 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 percent-
ages 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, aggres-
sion, 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 7

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 chron-
ically 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 fa-
thers 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 pen-
alty 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 par-
ents with responsibility for their minor children, because this may not always be consid-
ered.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 defen-
dants 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 clini-
cians 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.

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