The results show that girls were significantly more likely than boys to be admitted to the HIC-Y Herlaarhof for suicidal ideation, self-harm and emotional dysregulation. In fact, girls accounted for 80% of all admissions, while boys accounted for only 20%. The majority of these admissions (54%) were placements of patients from both central and southern parts of the Netherlands (large areas outside our region) so the results seem to reflect the national situation. Interestingly, regional and national reports of youth care services and probationary services show a majority of boys being admitted (56–89%).

Based on findings in literature we think that personal (diagnosis and coping strategies) and organisational factors may play a role in the underrepresentation of boys in the HIC-Y ward and their overrepresentation in secure youth care and probationary services [10,11,12, 14,15,16,17].

The question is raised how the experienced entrapment of the HIC-Y population relate to specific diagnoses. Literature shows that symptoms in people with psychiatric disorders may differ by gender [14,15,16]. Women with autism–spectrum disorder or attention–deficit hyperactivity disorder are believed to be underdiagnosed, and have been long neglected in psychiatric care compared to male peers, even when meeting the criteria for diagnosis [16]. This hints at a gender bias in psychiatry, meaning it is vital to remain vigilant for any subpopulations being underrepresented in care [14].

Since the HIC-Y accepts all patients with emotional dysregulation and suicidal behaviour, regardless of DSM diagnoses, the observed gender inequity cannot entirely be explained by a different incidence of psychiatric disorders, although timing can play a role. For instance, if girls with autism are underdiagnosed during infancy, they may be overrepresented during teenager years.

Moreover, our literature search of coping strategies revealed that girls tended to use more emotion-focused coping strategies which may conduct them to psychiatric care, while boys used more avoidant or solution-focused coping strategies (for example, vandalism, drug use and violence) which may conduct them to youth care and probationary services and keep them excluded from psychiatric care since these are exclusion criteria for many institutions [10,11,12].

HIC-Y are known to have exclusion criteria (see Appendix I). When behaviour disorders are the main focus or in case of instrumental aggression/violence or substance use, the teenagers is excluded from admission to the HIC-Y where psychiatric care is the main focus. Since the above-mentioned factors are coping mechanisms associated with males the question has been risen whether the way care is organized has driven boys with underlying psychiatric disorders into youth care and probationary services instead of psychiatric care (Fig. 1).

Exclusion criteria and gender disparities in access to psychiatric care: a comparative analysis, highlighting gendered coping strategies

A skewed gender distribution at acute youth psychiatric clinics (boys 37%) was already seen in the Netherlands before the implementation of the HIC-Y model in 2017 [17]. After implementation of the HIC-Y, we see a 30% further decline of male admissions (boys 20%) (Fig. 2).

Gender distribution in youth psychiatric clinics pre- and post-implementation of HIC-Y model in the Netherlands

Our observation of underrepresentation of boys (20%) at the HIC-Y differs from data of adult HIC units where only a slight majority of patients being admitted is male (56.1%) [18]. This emphasizes the institution of youth care as part of the care may underlie this. Once boys pass the age of 18, they are no longer eligible for juvenile care and are more readily admitted to adult HIC units.

In other countries, where youth mental health care is being organised differently, gender differences in admission rates are less extreme. A systematic review and meta-analysis found no association between sex and involuntary hospitalization in children and adolescents [19]. Two recent large studies from Jendreyschak et al. and Kandsperger et al., colleagues from our neighbouring country Germany, show no big gender difference in admission rates for teenagers, with boys accounting for, respectively, 57% and 41% of admissions to acute psychiatry wards [20, 21].

A recent Dutch study among General Practitioners dealing with psychosocial problems of children and youth in the Netherlands shows that they refrain from considering and consulting interdisciplinary teams if they had negative collaboration experiences, even if this choice resulted in poorer quality of care [22].

This finding corresponds with another study about cross domain collaboration in which poor communication, trust and support resulted in perceived patient delay [23]. These findings underline the importance of interprofessional collaboration as a key factor in initiatives designed to increase the effectiveness of health services [24].