Purpose ‐ The purpose of this paper is to describe how aggressive and violent incidents differ across specialist gender, security and mental health/learning disability pathways in specialist secure care. Design/methodology/approach ‐ The paper uses a retrospective survey of routinely collected incident data from one 207-bed UK independent sector provider of specialist medium and low secure mental health care for male and female adults with primary diagnosis of mental illness or intellectual disability. Findings ‐ In total, 3,133 incidents involving 184/373 (49.3 per cent) patients were recorded (68.2 per cent other-directed aggression, 31.8 per cent self-harm). Most incidents occurred in the medium secure wards but more than half of the most severely rated self-harm incidents occurred in low security. Men were disproportionately involved in incidents, but a small number of women were persistently involved in multiple acts. Incidents were most common in the intellectual disability pathway. Research limitations/implications ‐ Incidents, especially those of lower severity, can be under-reported in routine practice. Information about incident severity was limited. Practical implications ‐ Aggressive incidents do not occur homogenously across forensic and secure mental health services but differ substantially in their frequency and nature across security levels, and gender and mental health/intellectual disability pathways. Different approaches to training and management are required to ensure appropriate prevention and intervention. Future practice should draw on emerging theories of differential susceptibility. Originality/value ‐ This paper extends current knowledge about how incidents of violence and aggression differ across secure settings.