Correctional health care since the passage of PREA.

In 2003, Congress and President Bush issued a clarion call for change in American corrections to remedy the "dreadful degradation" of inmate sexual violence first described in 1826 by the Rev. Louis Dwight, president of the Boston Discipline Society. (1) Grounded in its commitment to the U.S. Constitution, the Prison Rape Elimination Act of 2003 (PREA) charted a course to identify, prevent, prosecute and respond to prison sexual violence in all correctional custodial institutions (adult and juvenile, public and private) and provide services to those victimized. In the four years since its passage, PREA has facilitated many positive, substantive changes in U.S. corrections, enhancing safety and security in institutions and the community. Many of these innovations have involved correctional health care and the delivery of much needed services to the victims.

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Who Are the Victims?

Although it is recognized that anyone can be the victim of inmate sexual violence, research has demonstrated that certain inmates are at increased vulnerability (e.g., the young; those new to incarceration; those with mental, physical and developmental disabilities; gay, lesbian, bisexual and transgendered inmates; and those previously sexually victimized while incarcerated). Because of the staggering number of inmates with mental illness in adult (2) and juvenile (3) correctional facilities, this potential for victimization represents an enormous challenge for corrections. Additionally, reports indicate that among the incarcerated an overwhelming number of women (4) and a substantial number of men have been victims of physical and sexual abuse as children and adolescents. (5)

Consequences

Correctional agencies are tasked with responding to a wide range of health care needs for victims of inmate sexual violence. In addition to injuries and trauma that may accompany sexual assault (often to get the victim to comply), a victim may be exposed to HIV/AIDS, other sexually transmitted diseases, and communicable diseases such as tuberculosis and hepatitis B and C, which are rampant in U.S. correctional institutions. (6) In addition to the provision of appropriate health care, forensic medical evidence must be properly and legally collected from the victim in a timely fashion if a criminal investigation or prosecution is to take place.

Emotionally, victims of inmate sexual violence may experience a variety of resultant problems, including suicidal ideation, post-traumatic stress disorder/rape trauma syndrome, anxiety, depression and a worsening of pre-existing mental health conditions. When victims face repeated victimization, they may view suicide as the only viable option. In the community, rape victims are four times more likely than noncrime victims to have contemplated suicide, and 13 times more likely to have made a suicide attempt. (7) However, the number of inmates who have attempted or completed suicide as a result of sexual violence is unknown. The effects of inmate sexual violence are also impacted by age and gender.

Impact on women. Incarcerated women have a much higher rate of physical and sexual victimization during childhood, adolescence and prior to their incarceration. (8) For women previously victimized, the impact of sexual violence during incarceration can be much harsher, interfering with their coping and recovery. Even worse, the ultimate betrayal of sexual abuse by correctional staff erodes their self-esteem and trust in the correctional system to protect them. (9) Women may also become pregnant as a result of their victimization.

Impact on men. Sexual assault devalues two primary aspects of male identity: sexuality and aggression. Most male victims experience concern about their masculinity, competence and security, which increases their humiliation and shame. (10) Men often manifest a more "controlled" response, which may lead authorities to conclude the event did not occur or to minimize its impact. A recent study reported that more men than women reported suicidal thoughts and attempts as a result of inmate sexual violence. (11)

Impact on juveniles. The crisis of adolescence is one of identity--knowing where one "fits in" in society and adopting an identity of who one is physically, emotionally and socially. Sexuality is a powerful force in the lives of developing teens. Following sexual victimization, juveniles may feel intense guilt and shame, and they are likely to blame themselves for their victimization.

Effective Management

To effectively manage the complex trauma experienced by victims, and to help them transition from victim to survivor, correctional agencies must ensure that adequate, competent medical and mental health care services are initiated as soon as possible to meet the short- and long-term needs of victims. These services must also continue as the inmate moves through the correctional system and is released to the community.

The health care services provided should be trauma-informed and trauma-specific (recognizing the impact of trauma), gender-specific (understanding the unique experience of women, men, gays, lesbians, bisexuals and the trans-gendered), culturally sensitive, and of sufficient duration to ensure that the victim will be adequately cared for. In addition, interventions should be practice-based (conforming to established clinical practice guidelines) and evidence-based to ensure they conform to community standards. Care must also be integrated and holistic, with each member of the health care team working collaboratively to meet the needs of the victim.

It must further be recognized that effectively managing inmate sexual violence is not simply a correctional health care function, but an integrated correctional function. Professional, competent health care delivery to victims of inmate sexual violence will ultimately fail if it is not part of a comprehensive, agencywide strategy for change. Correctional agencies seeking to implement an integrated approach may use the model illustrated in Figure 1, which provides a template for creating an agency's response.

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Stepping Up to the Challenge

Recognizing the unique aspects of inmate sexual violence, correctional agencies, particularly at the federal and state level, have instituted significant innovations, highlighted by a recent Urban Institute report. (12) These innovations can be clustered into five main areas:

* Formalized medical and mental health procedures;

* Use of sexual assault response teams (SARTs);

* Forensic evidence collection procedures;

* Collaboration with external agencies; and

* Peer education.

Formalized medical and mental health procedures. Inmate sexual violence is a crisis that requires a methodical response. The 2005 Survey of State Correctional Administrators, conducted by the Urban Institute and the Association of State Correctional Administrators (ASCA), found that nearly all state departments of corrections provide medical services that address injuries and conduct medical testing for common diseases. Initial mental health counseling and referral is provided in most states, but ongoing mental health care varies. The outstanding protocols of the San Francisco County Jail and the Federal Bureau of Prisons are models for any correctional agency to emulate. Another important protocol to examine is the comprehensive clinical protocol established by the New Jersey Department of Corrections, which provides a full spectrum of care and treatment.

Use of SARTs. As the rape-crisis movement gained momentum, it was recognized that multiple interviews about the crime could be difficult for victims. In response, the SART model was created to minimize the trauma of repeated discussions. These teams may include representatives from medical, mental health, law enforcement, prosecution and victim-advocate staff who work closely with victims to minimize the resultant trauma and provide necessary treatment. A number of state correctional agencies, notably those of Idaho, Kansas, Oregon and Utah, have adopted this model to provide appropriate, victim-sensitive service to victims.

Forensic evidence collection procedures. Competent and thorough forensic evidence collection is vital to criminal prosecution. The process is often lengthy, can be retrauma-tizing to victims and must be completed with exacting standards. The standard employed by most sexual assault providers in the community is the use of sexual assault nurse examiners. Prior to PREA, many correctional agencies did not specify systematic forensic evidence collection procedures in the event of inmate sexual violence. The situation has been dramatically improved as many correctional agencies have established collaborative agreements and memoranda of understanding with medical providers who employ sexual assault nurse examiners to complete forensic evidence collection.

Collaboration with external agencies. Until recently, there generally had been limited collaboration between correctional and community agencies. In addition to the national inmate reentry initiative, PREA has been the springboard for many important collaborations, especially in the provision of medical, mental health and rape-crisis advocacy services. Of particular note is the collaboration of correctional agencies with community rape-crisis centers. For nearly 30 years, community rape crisis and sexual assault agencies have been effectively meeting the needs of sexual assault victims, and innovative partnerships have emerged between them and state correctional agencies, most notably in California, Iowa, Ohio, Pennsylvania, Texas and Utah. Two collaborations in particular, California's Stop Prisoner Rape and the Pennsylvania Coalition Against Rape, demonstrate great promise. Both agencies have also published useful manuals (downloadable from their Web sites) on treating inmate sexual violence. (13)

Peer education. Using inmates as agents of support for other inmates has proved effective (14) and is a model worth considering. Several state correctional agencies, notably the Louisiana Department of Public Safety and Corrections and the Texas Department of Criminal Justice, have teamed with community providers to carefully train selected inmates, who then provide peer-based education and support to their fellow inmates on HIV/AIDS and management of sexually transmitted diseases.

Challenges

On the whole, state and federal correctional agencies (and some large jail settings) are admirably responding to the complex health care needs of victims of inmate sexual violence. However, significant challenges exist that must be addressed.

Correctional setting. PREA applies to all U.S. confinement institutions, but the smaller, less-funded agencies may be faced with great difficulties in achieving the law's requirements. Given this reality, it is incumbent upon correctional agencies to make use of national, state and local resources as much as possible. The National Institute of Corrections (NIC) continues to serve as a clearinghouse of PREA information and training and also provides technical assistance to correctional agencies through its cooperative agreements with other organizations. At the state and local levels, a number of community agencies (e.g., local hospitals, rape-crisis centers and community advocacy groups) exist that can effectively partner with correctional agencies. The Office of Victims of Crime maintains a searchable Web site, http://ovc.ncjrs.gov/findvictimservices, which correctional agencies can use to identify other agencies providing services for sexual assault victims.

Confidentiality. Sexual violence in correctional facilities means loss of confidentiality for the victim. A victim in the community can often confidentially seek medical and mental health care without the involvement of law enforcement. Due to the nature of corrections, and the responsibilities that correctional agencies have to ensure safety and security of inmates and the institution, this is not possible. Each state has its own legal requirements regarding patient confidentiality and privileged communication, which must be understood and adhered to by correctional health care professionals and correctional agencies. The essential policies, protocols and procedures developed by correctional agencies must respect these legal dictates. Additionally, correctional health professionals, to avoid unknowing revictimization, must clearly articulate the limits of confidentiality so that inmates understand what may occur.

Burgeoning correctional population. According to the Bureau of Justice Statistics, U.S. correctional institutions now incarcerate nearly 2.3 million inmates daily. Longer sentences and an increasing juvenile population complicate the challenge faced by corrections. Increasing populations also often force correctional agencies to transform treatment and program space into housing.

Fewer (and lack of) integrated resources. Restrictive local, state and federal budgets have minimized corrections' ability to properly house and maintain the ever-increasing population and to provide sufficient treatment programs and services. Also, correctional settings are becoming the dumping grounds for the mentally ill in the United States, and most correctional agencies are underfunded and understaffed, making correctional health care difficult. (15) Given the overwhelming challenge faced by correctional health care, and corrections as a whole, it may be time to seriously reevaluate who should be incarcerated and for how long.

Public attitudes. Correctional settings are microcosms of the larger society. Many people simply do not care about inmates, adopting the view "don't do the crime if you can't do the time" and thinking that what happens during incarceration is actually part of the punishment, an idea that is tacitly supported by the media. (16) By failing to make the connection that sexual violence and brutality will only create individuals who are angry, bitter and disordered, more likely to be self-destructive and/or aggressive, the cycle of victimization will continue.

The Future

In four short years, PREA has stimulated a sea of change in knowledge and understanding about a problem that has plagued corrections since the dawn of the penitentiary movement in the United States. Great work has begun, particularly in state and federal correctional agencies and some large jail settings, but much more work must be done. Managing the problem requires a systemic approach (17) advocated by NIC, which integrates all aspects of corrections (policies, procedures and protocols). To be sure, there are serious challenges to eliminating prison sexual violence and promoting effective treatment of those victimized. Yet corrections has risen to the challenge, with its characteristic strength of purpose and vigor, demonstrating its commitment to justice, public health and inmate reentry. Corrections must renew its efforts to provide adequate health care to all inmates, especially those who have been sexually violated. By doing so, the field is making an investment in a safer community for society.

ENDNOTES

(1) Katz, J. (Ed.). 1976. Gay American history. New York: Thomas Cromwell.

(2) James, D.J. and L.E. Glaze. 2006. Mental health problems of prison and jail inmates. Washington, D.C.: U.S. Department of Justice.

Kupers, T.A. 2005. PTSD in prisoners. In Managing special populations in jails and prisons, ed. S. Stojkovic, 10-1-10-21. Kingston, N.J.: Civic Research Institute.

Maruschak, L.M. 2006. Medical problems of jail inmates. Washington, D.C.: U.S. Department of Justice.

(3) Teplin, LA, K.M. Abram, G.M. McClelland, A.A. Mericle, M.K. Dulcan and J.J. Washburn. 2006. Psychiatric disorders of youth in detention. Rockville, Md.: Office of Juvenile Justice and Delinquency Prevention.

(4) Wolf, H.C. 1999. Prior abuse reported by inmates and probationers. Washington, D.C.: Bureau of Justice Statistics.

(5) Johnson, R.J., M.W. Ross, W.C. Taylor, M.L. Williams, R.I. Carvajal and R.J. Peters. 2005. A history of drug use and childhood sexual abuse among incarcerated males in a county jail. Substance Use and Misuse, 40(2):211-229.

(6) Glazer, S. 2004. Sexually transmitted diseases. CQ Researcher, 14(42):997-1020. Retrieved July 11, 2007, from http://library.cqpress.com/cqresearcher/cqresrre2004120300.

Hammett, T.M., P. Harmon and W. Rhodes. 2000. The burden of infectious disease among inmates and releasees from correctional facilities. Chicago: National Commission on Correctional Health Care.

National Institute of Justice/National Commission on Correctional Health Care. 2002. Health status of soon-to-be released inmates: A report to Congress. Vol. 1. Washington, D.C.: National Commission on Correctional Health Care.

(7) Kilpatrick, D.G., A. Whalley and C. Edmunds. 2002. Sexual assault. In National Victim Assistance Academy textbook, eds. A. Seymour, M. Murray, J. Sigmon, M. Hook, C. Edwards, M. Gaboury and G. Coleman, Chapter 10. Washington, D.C.: U. S. Department of Justice, Office for Victims of Crime. Available at www.ojp.usdoj.gov/ovc/assist/nvaa2002/chapterl0.html.

(8) Wolf, H.C. 1999.

Browne, A., B. Miller and E. Maguin. 1999. Prevalence and severity of lifetime physical and sexual victimization among incarcerated women. International Journal of Law and Psychiatry, 22(3-4):301-322.

(9) Dumond, R.W. 2006. The impact of prisoner sexual violence: Challenges of implementing Public Law 108-79: The Prison Rape Elimination Act of 2003. Notre Dame Journal of Law and Legislation, 32(2): 142-164.

(10) Dumond, R.W. and D.A. Dumond. 2002. The treatment of sexual assault victims. In Prison sex: Practice and policy, ed. C. Hensley, 67-88. Boulder, Colo.: Lynne Rienner Publishers.

(11) Stop Prisoner Rape. 2006. Hope for healing: Information for survivors of sexual assault in detention. Los Angeles: Stop Prision Rape. Available at www.spr.org/pdf/HopeforHealingweb.pdf.

(12) Zweig, J.M., R.L. Naser, J. Blackmore and M. Schaffer. 2006. Addressing sexual violence in prisons: A national snapshot of approaches and highlights of innovative strategies. Washington, D.C.: Urban Institute, Justice Policy Center. Available at www.urban.org/Uploaded PDF/411367_psv_programs.pdf.

(13) California's Stop Prisoner Rape: www.spr.org/pdf/HopeforHealingweb.pdf; Pennsylvania Coalition Against Rape: http://pcar.org/resources/PrisonRapeGuide.pdf.

(14) Devilly, G.J., L. Sorbello, L. Eccleston and T. Ward. 2005. Prison-based peer-education schemes. Aggression and Violent Behavior, 10(2):219-240.

(15) Clemmitt, M. 2007. Prison health care. CQ Researcher, 17(1):1-24. Retrieved July 11, 2007, from http://library.cqpress.com/cqresearcher/cqresrre2007010500.

Human Rights Watch. 2003. Ill equipped: U.S. prisons and offenders with mental illness. New York: Human Rights Watch.

(16) Eigenberg, H. and A. Baro. 2003. If you drop the soap in the shower you are on your own: Images of male rape in selected prison movies. Sexuality and Culture, 7(4):56-89.

(17) Moss, A and AT. Wall III. 2005. Addressing the challenge of inmate rape. Corrections Today, 67(5):74-78.

Robert W. Dumond, LCMHC, CCMHC, Diplomate CFC, who has worked in criminal justice and human services since 1970, is president and senior consultant for Consultants for Improved Human Services PLLC, providing training and consultation nationally to correctional agencies. Doris A. Dumond, MA, is senior researcher with Consultants for Improved Human Services, PLLC.