Today the amount of women in Special Hospitals constitute 20%. 1,2,3 Though still low in proportion to whole gendered population of over 1, 600 is much higher than the female prison population of 5% 4. The greatest disproportion between the psychiatric disposals of women and men is at the least coercive end-psychiatric probation orders where the rate for women is twice that of men 5. It is not due to decisions in court that the numbers of women in special hospitals is so high in relation to prisons, for 80% of women in special hospitals have already spent time in prison psychiatric units which suggests that the courts are failing to recognise the needs of women who are legitimately in need of psychiatric treatment, or that prison drives women 'mad', 6 or that harsh discipline is seen as an adequate treatment for 'mental illness'. In any case there seems to be a high degree of interchangeability between the notions of prisoner and patient. Instead of Special Hospitals appealing to women as a source of help and support they consistently fail to offer constructive treatment and the fact that a convicted woman once admitted to a special hospital loses her release date and can be detained indefinitely causes women to fear transfer no matter how bad her prison experience is 7. In this context, there appears to be considerable confusion throughout the criminal justice system about what to do about female deviance.

The studies included in the paper derive from articles and books on female confinement generally and from feminist criminology specifically from the available (but scarce) literature pertaining to women in special hospitals. In addition, official policy documents/inquiries have been utilised. This sociological literature review located the available relevant evidence in relation to women in special hospitals which simultaneously drew upon feminist-sociological literature on female confinement. A broader sociological perspective was warranted than reducing explanation to bio-psychological explanation which heavily utilises the process of psychiatrization.

A significant gap in the literature both nationally and internationally of women's experiences in such regimes was revealed. Articles excluded from the sociological review revealed an overall concern with concepts of 'security' and 'dangerousness' without any attention to empowerment and quality of life. Sociological studies included in the review revealed an overwhelming concern with issues of disempowerment of women in special hospitals.

There have been increasing concerns about provision of treatment and services for women in Special Hospitals. This concern has been articulated by Women In Special Hospitals (WISH) that services for women are insensitive and the provision is appalling. Coupled with this, there have been concerns that services for 'mental illness' are inappropriate and genuinely not meeting need. The Department of Health and Home Office Review of Services for Mentally Disordered Offenders (Reed Report) has recently highlighted the management of psychopathic and antisocial personality disorders as a topic for major consideration (Reed 1994) 8. The final report of the working group noted the paucity of methodologically rigorous research into the effectiveness of treatment of people in Special Hospitals with such a diagnosis.

However, treatment for women with and without such diagnosis in special hospitals has been far from empowering as the Blom-Cooper report (1992) reviewed. This inquiry found that the culture at Ashworth Special Hospital was anti-therapeutic in the light of women's lives. The culture of the hospital was found to be 'macho', 'militaristic' and 'male dominated' 9. The report posited that institutional neglect and abuse was prevalent especially as regard to women who were 'almost constantly emotionally abused and at times physically abused...they feel chronically frightened and overwhelmingly powerless' 10. The report concluded that 'the current regime for women is infantilizing, demeaning and anti-therapeutic. Mr Pleming for the MHAC (Mental Health Act Commission) could have been speaking for us when he stated'...the Commission's position, I hope it is clear, that radical changes...are necessary if women in Special Hospitals are to receive the type of care which will improve their situation' 11. Hence, the efficacy of services for women has been highlighted as disempowering, but what is needed is a sociological literature review which transcends the historically pre-dominant bio-psychological/positivistic framework which has espoused that female offending/deviance has been related to 'dangerousness' which in turn explains their medical diagnosis and level of security and consequent treatment.

Special Hospitals are secure psychiatric hospitals. The statutory basis for the current special hospitals which house 'mentally disordered' people derive from the County Asylums Act (1808)12. In the early 19th century, 'madhouses' were built to confine the 'dangerous lunatic' and on 6 August 1860 an Act was passed for the provision of 'custody' and 'care' of "criminal lunatics" which resulted in the instigation of Broadmoor in 1863 13. Alongside this, Rampton was opened in 1910 with Moss Side (now Ashworth) in 1914 14.

These institutions signalled the beginning of the United Kingdom policy of designing security for dangerous 'mentally disordered' people15. The move towards 'separate institutions' for 'dangerous' and 'non dangerous' patients emerged in the 1950's and 1960's with the development of the 'open door' philosophy in local N.H.S hospitals16. 'Mental Illness' was seen as akin to physical illness and special hospitals were designed to treat, not to confine, patients17. Research by Gostin (1986) has illustrated how the open door policy has caused intractable problems for a minority of 'less attractive' patients 18. Many mentally disordered people were sentenced to imprisonment because courts could not find suitable placements. The governments' response to this problem was to construct more specialisation. Secure units were planned in each regional authority in England and Wales. These Regional Secure Units (RSU's) are operational today. However, admission to such special hospitals are underpinned by legal categories and discretion of clinical judgements of the constitution of 'mental illness'.

Officially, the Secretary of State has a duty under Section 4 of the N.H.S Act (1977) 'to provide and maintain establishments...for persons subject to detention under the Mental Health Act 1983 who in his opinion require treatment under conditions of special security on account of their dangerousness, violent and criminal propensities' 19. The hospitals established under Section 4 are entitled 'Special Hospitals': Broadmoor, Rampton and Ashworth.

The definition in Section 4 of the 1977 Act portends that special hospitals can only be used for patients liable to detention under the Mental Health Act. However, according to Gostin (1986) there have been cases where informal patients have been kept in special hospitals-for example, after a Mental Health Review Tribunal (MHRT) has discharged a patient fro being liable to be detained 20. Ironically, special hospitals are maximum security institutions which in principle should not house informal patients.

The term 'Special Security' in Section 4 of the 1977 Act has been construed as meaning that it should not be less secure than that required for the most 'dangerous' (Category 'A') prisoners. In practice, the security in special hospitals is preserved by a secure parameter wall, locked wards, the 'caution' of staff and a system of constant checks 21. Security it seems is paramount to prevent the threat of 'dangerous' individuals from harming other patients and staff.

Hence, only patients with 'dangerous, violent or criminal propensities' should be detained in a special hospital. This means that if a patient clearly does not meet these criteria it would be unlawful to detain him/her in a Special Hospital. Yet, a study by Dell (1980) found that patients were admitted into special hospitals in spite of the Secretary of State's view that they did not require conditions of special security 22. Special Hospitals were built as maximum security institutions for highly 'dangerous' individuals. Hence, such regimes restrict a person's freedom and quality of life. It is a 'liberty' issue which should involve the patient having basic democratic rights. Yet, the very narrow and positivistic conceptualisation of the 'dangerous' patient pervades any discussion of empowerment because of 'security risk'.

According to the admission policy of Ashworth Hospital Authority, there are 3 factors which play a crucial role in admission: firstly, 'The presence or absence of recognisable mental disorder'; secondly, 'liability to detention' and thirdly, the level of 'dangerousness' 23. The policy makes it clear that constant surveillance can only be justified when the highest levels of security are required and less security would not provide a safeguard to the public because of these 3 factors. What the Admission policy overlooks is the safeguarding of patients which was addressed by the findings of the Blom-Cooper report (1992) which found neglect, abuse, infantilisation and disempowerment as pervasive amongst patients. It is in the context of these factors that treatments in special hospitals are operationalised.

The structure and organisation around current treatments in Special Hospitals is orientated around the following: Drugs, Psychiatric treatment, Electroconvulsive therapy (ECT), Psychotherapeutic treatment, Milieu therapy, counselling and social therapy (Blom-Cooper 1992) 24. However, a study by Stevenson (1989) has illustrated that such treatments disempower women specifically because of the overuse for example of drugs 25. Many women have become excessively dependent upon psychotropic drugs and which if stopped too quickly can leave women feeling more vulnerable because of the dependence upon them. In relation to ECT-where a patient is severely depressed and suicidal and the patient has given permission is seen as a last resort treatment for patients. However, Stevenson (1989) found that ECT was given to some women without consent again adding to their marginalisation. ECT is seen as punishment for unacceptable behaviour not as treatment or of value as empowering. Regarding Milieu therapy, this is the theory that individuals get better by virtue of being in that environment or milieu. Stevenson (1989: 16) quotes a woman in Rampton: 'When I used to work in the sewing room on the machines, they used to say that was treatment-going to that room every day and sewing'. Arguably, this treatment epitomises feminisation as proof of normalisation/institutionalisation. In relation to talking therapies, the principle problem identified: how can a woman patient trust the person they are talking to/being treated by when part of their job is to report on her and be her jailer? Part of the problem as McCabe (1996) identifies is that women patients feel they are not listened to 26. There seems to be an awareness of the need for and the value of talking therapies (Blom Cooper 1992) but has yet to operationalised (McCabe 1996; Adstead and Morris 1996; Eaton and Humphries 1996).

Much discussion of the priorities of the HSPCB (1997) is 'gender versus integrated services' 27. One of the main critiques of the existing provision of services is how incompatible male and female services are in combination. Using the term of integration for treatments for both men and women in the context of mixed wards in hospitals is misleading as it suggests a harmonious whole. Centrally, how can women be integrated or normalised into a male environment? There are few alternatives for women to special hospitals with overcrowding a key feature of Regional Secure Units (RSU's). Women become trapped within a system orientated around lack of alternatives coupled with a reluctance by psychiatrists to discharge women into the community.

Indeed, since the 1970's, sociologists have developed sophisticated research methodologies on female offenders which expose the gender differentiated processes underpinning service provision and show how such processes operate in subtle yet complex ways. These studies stand in direct opposition to positivistic hypothesis testing models which attempts to quantify statistical correlations of cause and effect of criminality and levels of dangerousness 29.

This review examined complex social processes that lay behind the categorisation of female confinement and how gender assumptions/stereotypes played a pivotal feature in the subordination of such confined women in prisons/special hospitals. This review drew heavily upon historical/contemporary official documents and sociological-feminist analyses about female confinement and experiences which can be utilised to explain the marginality of women in such regimes.

What the sociological literature points to is that gender stereotyping plays a crucial role in the labelling of female offending and social processing of criminalisation. A study by Allen (1987) reveals that women appearing before the court are twice as likely as men to be dealt with by psychiatric means 30. Women are more likely to be referred for psychiatric reports, more likely to be found insane or of diminished responsibility and importantly more likely if convicted to be given psychiatric treatment at a Special Hospital in place of a penal sentence. Allen (1987) claims these findings cannot be explained by differences in the mental health of male and female offenders. Clinical judgements of 'abnormally aggressive or seriously irresponsible conduct' are applied very differently to women and men. What Allen (1987) found looking through court evidence was that the diagnosis of 'psychopath' in men was linked to the manifestation of violence; for women, fighting, thefts and sexual promiscuity were taken into account. Hence, the very application of medical classifications to men and women are prescribed via socially constructed attitudes and expectations of gender roles.

Allen's (1987) work builds upon the work of Rowett and Vaughan (1981) who found that mental institutions are devices used by dominant groups to control and regulate the behaviour of unacceptable marginals 31. Such is the social construction of medical classification, Rowett and Vaughan (1981) quote Partridge (1953) who chronicled the history of Broadmoor: 'Insanity is often brought on by child rearing...Individual pride in her personal appearance seems to be the requisite to a recovery of a woman's sanity' 32. Hence, pride in a feminine appearance fulfils the gender stereotype.

The work of Carlen (1983) illustrates the subjective meanings of female confinement and with particular reference to the wider meanings of the experiences of prison 33. Carlen's (1983) study makes use of interviews with Sherrifs (Judges), police officers and social workers and utilises observation in prisons and courts incorporating a Kaleidoscopic (diverse methods) approach. What is revealed by the talk of all those interviewed is the network of interests which underlie the logic and imagery of the judicial and penal systems when they attempt to represent the 'inadequate' woman. Carlen (1983) details the ways in which the confinement of recidivist women offenders is over-determined by the gender assumptions of law enforcers who interpret the law via discretion and consequently attach the label of 'criminal' to females. Carlen's (1983) work raises significant questions as to the meanings of imprisonment and the penal disciplining of women. Coupled with this, the use of psychiatric labels such as 'personality disorder' continues to reinforce the disempowerment of women. As Carlen (1983) has argued, although it cannot be conceptualised the application of the label makes 'women feel quite 'horribly at home' within psychiatric careers'. Hence, normalization through psychiatry is underpinned by medical mechanisms for maintaining security. For example, there has been an increase in psychotropic drugs because 'women can be pretty wicked without the drug' (Nursing Doctor quoted in Carlen 1983: 200). A study by Genders and Player (1987) exemplifies Carlen's research as they have indicated that between 1984 and 1985 over 145, 000 doses of anti-depressants, sedatives and tranquillisers were dispensed to women proportionately five times as many doses as men received in psychiatric units 34.

Adshead and Morris (1996) claim that women are contained in Special Hospitals because of huge discrepancies in the provision of mental health care 35. These treatments (psychtropic drugs/social-psycho therapies) are unsuitable and damaging because they are designed by males for male offenders. One of the central points gathered is that women in Special Hospitals do not require the level of security offered there. Many of the women are suicidal and self-harmers with 80% of the female special hospital fitting this description and are in chronic need of therapy/empowerment not containment/security. These authors claim that the Special Hospital like prisons brings stigmatisation and a perception of a 'shameful place'. Consequently, special hospitals infantilise and punish women. They argue that levels of 'dangerousness'/perceptions of risk are not proportionate to reality. Similarly, work by McCabe (1996) has illustrated that security and containment take precedence over therapy 36. According to her, women can become institutionalised and can expect to be in special hospitals for years which adds to stigmatisation and makes rehabilitation difficult.

A study by Eaton and Humphries (1996) is one of the first to analyse the experiences of women in special hospitals 37. These authors utilised a qualitative approach in which 15 women were interviewed from each of the special hospitals. What these authors claimed was that quantitative research would constrain women to answer set questions which does not reveal subjective experiences. Meanings and Life Histories were articulated via interview methodologies. This was a useful way of researching women as it gave respondents chances to elaborate upon experiences as opposed to measuring answers via structured/quantified questionnaires.

One of the main points gathered by Eaton and Humphries (1996) is that women must feel understood if they are to feel empowered. Empathy may help women deal with their emotions/feelings rather than self-harm. As Eaton and Humphries (1996) state there is a fundamental need for a supportive environment.

Progress in research comes from building on the efforts who have worked before and this is exactly what the work of Hemingway (1996) illustrates.

In a collection of papers drawing from multidisciplinary perspectives, Hemingway (1996) et al. locate the oppressive experiences of women in special hospitals 38. Hemingway (1996) posits that women's experience of 'abuse' highlights an inability of the special hospital to protect women from physical, emotional and sexual abuse at the hands of patients and staff. Whilst the special hospital pontificates issues of security, they consitently fail to provide security to those people inside its own regime who require it most. In addition, Hemingway (1996) claims women lack any control over their own lives and are ignored. Thus, special hospitals are not as Hemingway (1996) illustrates, so special in providing care/rehabilitation because of the distrust of patients who have been defined as 'mentally ill'/'dangerous'.

One of the points made by Brown and Burkett (in Hemingway 1996) is that notions of femininity and domesticity play a central role in the experiences of women patients in special hospitals. What these researchers indicate is that femininity is a factor in the control of women and as proof as re-normalisation. Coupled with this, Dolan and Brand (1996) (Hemingway 1996) claim that the use of drugs is widespread and Brown (1996) claims there is little or no treatment for women who remain powerless. This paints a picture as women in special hospitals as ignored, lack any control over their own situations/lives and have few role models. In combination, Hemingway et al. locate special hospitals as anti-therapeutic and as adding to the marginality/desperation to which women feel.

It is absolutely clear from the literature review of official and unofficial documents that in the context of methodology, quantitative analysis has informed policy and practice developments via an analysis of risk and 'dangerousness' without any use of qualitative epistemology or how to improve women's situation. What is lacking from perspectives however is a questioning of the concept of 'dangerousness' or the theorisation of masculinity and its impact on women in special hospitals.

A central question is what constitutes 'dangerousness'? Themes of individual pathology influenced by a wider familial environment has been the dominant framework which explained female dangerousness and this is highlighted by the use of milieu therapy. However, it would seem that the policy of secure specialised provision for 'dangerous' patients is based upon unfounded yet taken for granted assumptions. As Bowden (1985) points out 'dangerousness' is not such a clear and well conceptualised term 39. Hence, 'dangerousness' is not a constant, fixed personal characteristic. Rather, mentally disordered people may pose a 'risk' (Parton 1995) at certain times 40 and in response to certain situations but not in others; for example, highly vulnerable women can be 'disruptive' than very 'dangerous' in terms of behaviour. Such labels become constructed and applied via complex processes of negotiation, classification and rapport between patients and professionals.

Hence, there is a need to transcend images of dangerousness and locate the institutional mechanisms by which women in such regimes are manipulated to facilitate perceptions of legitimated social control, masculinity and power. However, admission to a secure institution is a self-fulfilling prophecy; patients come to be regarded as 'dangerous', otherwise why would they be there. It is important to recognise that all women in Special Hospitals are not fearless, manipulative and violent. Fear can be a constant factor in the daily lives of the majority of women in Special Hospitals. According to Stanko and Hobdell (1993: 27) this may often leave individuals 'isolated and unable to ask for support' 41, 42, 43.

Worrall (1990) claims that conformity to a feminine role is negotiable; it is not an absolute requirement. It can be negotiated within the family, within communities and in the larger society, but women have to have something to negotiate with. As Worrall (1990: 34) argues 'Class, race and age all affect the extent to which women can resist the ideological discourse of femininity' 44. The route by which women come to be either in court or in a Special Hospital is that someone (sometimes the woman herself) has identified their behaviour as deviant and there is a requirement that they be judged as either normal/innocent or mentally abnormal/guilty (Worrall 1990). In order to draw such attention, women may have breached the terms of their negotiated feminine role or they may actually have been conforming to a negotiated feminine role not recognised by those in authority. In this way the structural questions around the special hospital regime, its philosophy and practice are translated into individual psychological problems situated on a coping-non-coping continuum. It seems, therefore, whether as individuals or as groups, women are continually put under the microscope with every movement, gesture and response magnified and recorded by predominant 'scientific/clinical' observation.

Behind the walls of the special hospital, medical personnel including psychiatrists, psychologists as well as psychiatric social workers test, probe and hypothesise about women constructing and re-constructing quantifiable profiles of the bio-psychological and narrowly conceptualised sociological factors deemed to be lying at the root of their 'instability' (Carlen 1985) 45. Such individualised responses generates intervention into women's lives and reinforces the view that it is their problem rather than the pressurised structures and policies of the hospitals which are at fault (Adshead and Morris 1995) 46.

According to the work of Connell (1987: 187) utilising a concept such as 'hegemony' is particularly useful in recognising the relationship between domination and disempowerment 47. Alternative definitions of realities and ways of behaving are not simply obliterated by power networks. Thus, while physical and psychological violence might be a cornerstone of female confinement which support dominant cultural patterns and ideologies, they are utilised within a balance of forces in which there is an everyday contestation of power and where there is always the possibility for individual, social and historical change (Connell 1987: 184) 48. Domination is emphasised at the expense of contradiction, challenge and change both at the level individual identities (women) and social formations (staff/regimes). This position is particularly relevant for the study of women in special hospitals for despite the domineering brutalisation/disempowerment/infantilisation which underpins and reinforces the culture of masculinity inside, this culture has often been undercut by individualist and collective strategies of dissent (WISH) and sometimes by alternative official discourses (Blom-Cooper 1992) which have provided a glimpse of the possibility for constructing social arrangements which are not built on violence and domination in such regimes.

The 'hegemonic masculinity' (Connell 1987) and the controlled use of violence which prevails in Special Hospitals with its female population exemplifies a broad pattern of physical violence, psychological intimidation which provides a stark yet chilling context in which everyday decisions are made, lives controlled and bodies and minds broken. The process of normalisation and routinisation underpins and gives meaning to the self-perception of the individual and the perceptions of the significant others in the power networks of the institution. As a comparison to the prison system, the work of Sim (1994) 49 makes the point that prisons sustain, reproduce and indeed intensify the most negative aspect of masculinity, moulding and re-moulding identities and behavioural patterns whose destructive manifestations are not left behind the walls when the prisoner (or even patient) is released. Disempowerment on the inside it seems can be mirrored on the outside.

A gendered reading of the social order and hierarchies of the female special hospital moves therefore beyond bio-psychological models and organisational imperatives or individualised profiles. What we need to point to is how the maintenance of order/security both reflects and reinforces the pervasive and deeply embedded discourses around particular forms of masculinity.

The mortification which women undoubtedly experience in their daily lives does nothing to alleviate the problems that the majority will face on their release into the community. Rather in its very 'celebration of masculinity' (Scraton et al. 1991) 50, the Special Hospital, like other state institutions such as prisons, materially and symbolically reproduces a vision of order in which 'normal womanhood' remains unproblematic, the template for constructing everyday social relationships between men and women prisoners/patients/professionals working with them.

Professionals who refuse to work within the bounds of accepted practices organised around discourses of power, authority and domination which underline, underpin and give meaning to the working lives of the majority of professionals/managers both on the ground and within the bureaucracy of the state. Ideologies and behaviour which legitimises disempowerment can be tied to issues of masculinity. Attempting to step outside a swamping disciplinary culture results in alienation, stress, lack of promotion and overt hostility from the majority. Potier (1995) (former member of staff at Ashworth) claims after she gave evidence to the Blom-Cooper commission, she received intimidating telephone calls at her home (Lloyd 1995).

Special Hospitals are exclusively male environments (Adshead and Morris 1995) 51. The number of female nurses, for example, is correspondingly small. The historical development of the special hospital and the emergence of atypical culture has led to perceptions of females as 'weak'. In contrast, an emphasis on physicality and masculinist attributes corresponds closely to what Morrison (1990) has described as a 'tradition of toughness' 52. This dense 'macho culture' of Special Hospitals featured prominently in the criticisms of the recent public inquiry which as mentioned previously furnished an uncompromising indictment of institutional neglect and abuse.

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