Health care for women offenders.
The population of incarcerated women underwent profound change in the 1980s, as did the impact of women offenders on jail and prison systems. Some of this is related to the fact that American jail and prison populations became the world's largest during the past decade.(1) However, the real change in focus on women is associated with the impact on correctional systems of increasing and intensified demand for specialized health care services hitherto not delivered on a large scale in prisons and jails.
The largest American prison and jail systems, such as those in New York and California, have not traditionally been called upon to respond to the special health care needs of large populations of women or even to provide basic parity of the quality and availability of primary care afforded men. Jail and prison health care systems have largely been defined and operated by men for a nearly exclusive male clientele. In New York, for example, 18 county jails (35 percent) had no services for women in 1990; in fact, they were unable even to detain women. Women in these regions were boarded out to the relatively few facilities that would accept them, leaving incarcerated women far from home, family supports and legal counsel.(2)
The medical problems of urban minority women are usually more severe and intractable than those of their male counterparts. In most large correctional systems, women offenders, particularly minority women, have the highest rates of HIV infection and associated tuberculosis (TB), far exceeding rates for male offenders. In New York, mortality among incarcerated women remains more than twice that of women in the same age group in the community.(3)
High-risk pregnancies and premature deliveries can be expected to increase annually with the growth in offender census. The growing population of incarcerated women also has evidenced high rates of mental health problems. A California study found more than 40 percent of incarcerated women with a DSM-III-R (IV) diagnosis.(4) Anxiety disorders predominated among incarcerated mothers and grew proportionately over time. A high prevalence of depression was found among both mothers and nonmothers.(5)
As both the volume and intensity of demand for services rise in coming years, prison and jail administrators will be required to critically examine their traditional male-centered health care delivery models and focus on the needs of women. An emphasis on managed primary care, on planning parity of services for women in new systems and on changing attitudes and beliefs antithetical to quality care for women must come about as women offenders become an ever-larger fraction of the criminal justice clientele.
Women in Custody
The last half of the 1980s saw a dramatic increase in the number of women committed to local jails. Nationally, the census of women in jail increased an average of 6.8 percent annually between 1990 and 1995, a rate two-thirds greater than that of men during the same period.
In New York, the second largest American jail system, women represented 5 percent of jail admissions in 1984. By 1990, 14 percent of jail admissions were women and that proportion remained constant through 1993. Moreover, women no longer went to jail for criminal court processing and expedited release; they remained as detainees and local sentence servers. In upstate New York and Long Island in 1984, 13,000 women were sent to jail, but the average daily census was only 550. In 1992, there were 19,600 total admissions of women and a daily census of 1,160, a proportional increase of 50 percent.(6) Women were sent to state prisons at a rate that increased faster than jail admissions.
In 1984, New York's prison system incarcerated about 900 women on an average day, in just two facilities. By 1995, New York's average daily prison census of women was 3,615, held in eight facilities. The mean annual increase in New York's population of imprisoned women was 14 percent during that period as was California's, compared to an annual growth in male inmate populations of 8 percent and 12.5 percent, respectively. In 1994, this growth leveled off at 10.6 percent, a figure still higher than the increase in male inmates (8.5 percent).
Much of this extraordinary change is a function of the involvement of women in the substance use culture. Between 1980 and 1984, admissions to New York jails for drug-related charges increased at an annual rate of 13 percent. Beginning in 1985, the annual rate of increase tripled to 39 percent; commitments of women for these charges increased accordingly. In 1984, 640 women were admitted to jail for drug possession or sale; by 1990, 2,468 women were charged with drug crimes and sent to jails in upstate New York and Long Island.(7) It is clear that women are changing the demographics of prison and jail populations in the United States and with it the picture of inmate morbidity and health care delivery imperatives.
Health Care Needs
The social histories of women offenders are instructive in exploring their health problems as a group. The vast majority of female inmates are poor minority women with substandard housing, legitimate incomes of less than $500 per month and dependent children. Thirty-two percent head broken homes, 53 percent come from broken homes and 41 percent report a history of sexual or physical abuse.(8) These women have limited access to community-based health care systems and limited experience in negotiating their complexities. To an increasing extent, women as a group are immersed in the illicit drug culture as alcoholics, addicts, or the domestic partners of alcoholics or addicts. Recent studies of syphilis reveal that its incidence follows that of cocaine use in a manner which suggests an increasing prevalence of sex-for-drugs exchanges not explained by prostitution alone.(9)
The medical problems of women are associated with these conditions and behaviors; they most often include asthma, diabetes, HIV/AIDS, TB, hypertension, unintended, interrupted or lost pregnancy, dysmenorrhea, chlamydia infection, papillomavirus (HPV) infection, herpes simplex II infection, cystic and myomatic conditions, chronic pelvic inflammatory disease, anxiety neurosis and depression.
Wherever women offenders have been available in numbers sufficient for reliable study, their mental health service needs have been shown to exceed those of men. Anxiety and depression are the most significant mental health problems among women inmates, with some recent evidence that many women suffer from post-traumatic stress disorder. while in jail. Mothers and nonmothers typically show similarly high levels of depression. The mean depression level shown by a sample of incarcerated women assessed with the Center for Epidemiologic Studies' Perceived Depression Scale was more than twice that found in general population samples of women using the same instrument.
At the North Carolina Correctional Center for Women, among the 41 percent of women inmates who reported histories of physical and sexual abuse, the phenomenon of being locked up in a small space by intimidating male authority figures can be a potent stressor. A woman's first symptoms of post-traumatic stress syndrome may be encountered here, something not considered for either sex until recently, and then mistakenly thought to be confined to combat veterans. Abused women inmates often exhibit histories of long duration involving multiple episodes at the hands of fathers, husbands, boyfriends and strangers, and this abuse is often directly linked to the offenses for which they find themselves in jail.(10)
HIV/AIDS and TB
Women have been identified, along with adolescents, as the fastest-growing group of HIV-infected people in the United States.(11) The rate of HIV infection among female prison inmates now exceeds that of men in nearly every large correctional jurisdiction in the United States. AIDS was the leading cause of death for women ages 25-34 in New York City as long ago as 1987.(12) In the Texas Department of Criminal Justice, the female HIV seroprevalence rate is 7 percent, compared to 3 percent for men; in Maryland, 15.5 percent of women inmates are seropositive, compared to 8.7 percent of men. North Carolina found its HIV infection rate for women inmates to be nearly twice that (6.1 percent) of men (3.1 percent).(13) In New York, 20 percent of women prison entrants are HIV-positive, in contrast to a 9.2 percent rate for men,(14) with cumulative AIDS case rates 6 percent higher than male inmates and equivalent mortality rates of 70 percent.(15)
The incidence of TB among women inmates is following that of HIV/AIDS. Nine percent of the sample of women admitted to New York state prisons were PPD positive for TB and 2 percent had evidence of active disease. Contrasted with an overall reported rate of TB for New York's prison system of 271 cases per 100,000 in 1991, it becomes apparent that occult HIV cases among women prison entrants are correlative with TB. The TB rate for men in New York prisons actually fell from 202 cases per 100,000 in 1991, to 143 in 1992 (-29 percent). Rates for women, however, increased from 200 cases per 100,000 in 1991 to 228 in 1992, an increase of 14 percent and a rate 59 percent higher than men.(16)
Respiratory asthma has been increasing in the United States and Europe since the early 1970s, but its incidence among women has accelerated since 1980. Mortality from asthma increased 31 percent among all groups between 1980 and 1987, but mortality among women increased 50 percent during this period, as compared to a 23 percent increase for men. The rates are also consistently higher for blacks. The greatest increase in newly detected asthma cases occurred among young women, an increase of 69 percent in this group over the period, but rates were higher for females in all age groups.(17)
Reproductive Tract Disease
The relationship between reproductive tract disease and the general health of poor and minority women has not been thoroughly studied. Interviews and focus groups conducted with poor women and their health care providers throughout New York in 1991 elicited a widespread complaint that the medical community discounts the importance of reproductive health to the overall wellness of women.(18) This often forces poor women to act as their own primary care coordinators, evaluating and referring themselves for subspecialty care needs.(19)
With the emergence of women as a statistically relevant aspect of the HIV pandemic, interest has begun to focus on reproductive tract disease as a cofactor and/or marker in HIV/AIDS and in associated drug use behaviors.(20) A significant fraction of women in the New York study of women's health who found themselves with HIV infection reported long-standing, untreated pelvic inflammatory disease, HPV, consistently mutagenic Pap smears and chronic dysmenorrhea.(21)
The most visible, growing and problematic health care issue for incarcerated women is pregnancy and childbirth. The incidence of admission of pregnant women to Alameda County, Calif., jails doubled during the 1980s.(22) In New York, about 7 percent of women admitted to state prisons in 1991 were pregnant. This influx becomes more problematic when one considers that New York state law allows pregnant women inmates to live with their infants at the prison for up to 18 months, postpartum.(23) Further complicating this picture are well-founded suspicions that pregnancy can mask the symptoms of HIV disease or misdirect clinicians in cases where HIV symptoms mimic those of a high-risk or even normal pregnancy.(24)
Care of newborns of HIV-infected mothers is a complex and daunting task, particularly if complicated by drug dependence in the infant. Studies of HIV seroconversion in neonates from seropositive mothers ranged from 20 percent to 50 percent and was often complicated by concomitant infection with STDs, hepatitis B or C, TB and congenital opportunistic infection.(25)
Impediments to Health Care
Reproductive health care access notwithstanding, the systematic denial to women of parity of services readily and routinely available to incarcerated men is the most widespread and invidious impediment to adequate health care for women offenders. Alternate levels of care, such as skilled nursing care, chronic and rehabilitative care for the physically disabled, services for geriatric inmates, sheltered communities for the retarded and developmentally disabled, renal dialysis, reconstructive surgery, investigational therapies and cardiovascular surgery are all routinely available to men in federal and large state correctional systems. They are generally unavailable, restricted or provided on an ad hoc basis to women.(26,27)
The available research characterizes mental health treatment for women offenders as "conspicuous by its absence," and almost entirely focused on the needs of men.(28) Current widely accepted standards for prison health care proceed on the assumption that when standards are met, women have the same access to quality primary and specialty care as men in addition to the services unique to them as women.(29)
A Model of Improved Care
While the reflex defense mechanisms of state and local governments when confronted with prison reform litigation often become impediments to improved care, the courts have prodded some jurisdictions into development and implementation of improved women's services.
In California, Santa Rita County officials implemented a consent decree in 1989 in settlement of Jones v. Dyer, which established comprehensive OB/GYN and prenatal services for incarcerated women.(30) It features a new, $174 million facility, which is staffed according to a specially tailored $21 million provider contract. The OB/GYN unit is staffed by a multidisciplinary medical team composed of a perinatal case manager, a nurse practitioner, a physician and a nursing staff. All women admitted to the facility are afforded comprehensive reception health appraisal and are screened for pregnancy. Pregnant substance users are immediately sent to the outpatient OB service of the hospital, evaluated and enrolled in a substance abuse treatment program.
All pregnant women receive relevant prenatal laboratory studies, ruling out diabetes, HIV, HBV(C-D), TB, HSV, etc. A Pap smear and STD serologies are obtained. Therapeutic abortion is available upon request. Counseling with credentialed mental health professionals is immediately available. Women are placed on a therapeutic prenatal diet with appropriate supplements. Ultrasonography is done at 16 to 20 weeks. Pregnancies complicated by risk factors or illness result in admission to a 32-bed, inpatient unit with 24-hour nursing. A structured exercise program conducted by qualified staff is provided. Social services, which include information and assistance on adoption, resources and coping skills for single-parent mothers, options and skills for child care, and family planning, are provided.
Santa Rita's experience shows that there is little mystery regarding the operational components required for establishing credible, comprehensive, primary care services for women. Poor correctional health care for women is not a function of staff or equipment, but rather a manifestation of pervasive and insidious attitudes, behaviors and beliefs which influence government policy. State and local government policy-makers who elect to improve the quality and availability of health care for incarcerated women in advance of a court order to do so should focus on education and training, installation of modern, managed primary care models, health care finance strategies, and emphasis on diversion and aftercare.
Women offenders need to develop living skills that raise self-esteem and build confidence necessary to avoid high-risk behaviors; to negotiate the complexities of the health care system as consumers; and to adopt wellness as a primary personal value. Health care providers should be required to demonstrate satisfactory skills for delivery of respectful and considerate care in a sexually and culturally diverse society while in medical and post-graduate school and on a mandatory continuing medical education basis. Many medical professionals would do well to learn and adopt a less judgmental approach to their patients and trouble themselves less over whether offenders deserve their skill and effort.
Managed primary care for women seeks not, as the third-party payors might have it, to keep shut the access gate to the health care system, but to draw all clients into promotion and maintenance of health. This requires that correctional medical departments implement aggressive protocols for identification of, and intervention in, medical problems; manage patients within diagnostic cohorts; emphasize wellness; promote continuity; and place a premium on care that is respectful and considerate. The present demand-for-service and episodic style of ambulatory care in jails and prisons treats each encounter as unprecedented, each complaint as isolated; it is the single greatest impediment to quality of care.
As the enormous growth of health costs imperils our world economic position even as we ration health care to the poor, the United States is now compelled, however unwillingly, to adopt a universal health care access and finance system. Medicaid, the primary health finance guarantor for the poor, is summarily denied to prison and jail inmates under federal Title 42 CFR while they are incarcerated, even to those participating prior to incarceration. A great deal of preventive health care while in custody is deferred for lack of Medicaid reimbursement. There is no justifiable rationale for such an anomaly. Deferral of care benefits no one; it inflates the cost of care, which inevitably must be delivered later at higher levels of acuity. Planners of universal care systems for the new century would be well-advised to revisit health care financing for the incarcerated.
Reduction in unnecessary incarceration of women will serve to reduce demand for scarce specialized services. For those women who must be incarcerated, planned referrals to post-incarceration services with emphasis on Medicaid eligibility, family planning, drug abuse services and coordinated health maintenance for mothers and their children should be emphasized.
The irony of Santa Rita County Jail as quite possibly the highest quality comprehensive health service provider for poor women in its community is an instructive one. The subpopulation of women offenders comes from the growing pool of poor and often victimized women in our urban centers who are quickly returned there. Their health problems and needs do not arise in prison; rather, the women bring their health care problems to prison. Informed commentators now discuss jail as the social net of last resort, providing neither punishment nor deterrence, but rather respite from hopelessly untenable life situations and access to health and human service programs unavailable in their home communities.(31) If this is indeed the case, then the correctional institution has, for better or worse, become integral to the community. The line between the inmate "others" and the rest of us is no longer so clear, and the right to decent health care is no longer exclusive.
1. Butterfield, F. 1992. Are American jails becoming shelters from the storm? New York Times. (July 19).
2. New York State Commission of Correction (SCOCa). Statewide Data Compilation from Sheriff's Annual Reports: 1984-1993. Albany, N.Y.
3. New York State Executive Chamber. 1994. Report of the interagency work group on women's health. Women's Health. Albany, N.Y.
4. Fogel, C.I. and S.L. Martin. 1992. The mental health of incarcerated women. Western Journal of Nursing Research. 14(1):30-47. The DSM III-R, now the DSM-IV, is the comprehensive diagnostic and classification system for mental disorders. All valid diagnoses are made from this compendium, which enforces consistency and omits such diagnoses as "hysteria."
5. Fogel, C.I, et. al.
8. U.S. Department of Justice. Bureau of Justice Statistics (BJSc). 1992. Sourcebook of criminal justice statistics, 1991, 611-630. Washington, D.C. See also: (BJSd) Women in prison, 1991.
9. Farley, T.A., J.L. Hadler and R.A. Gunn. 1990. The syphilis epidemic in Connect/cut: Relationship to drug use and prostitution. Journal of Sexually Transmitted Diseases. 17(4): 16-8.
10. Browne, A. 1987. When battered women kill, 23. New York: Free Press.
11. New York State Executive Chamber. Women's Health.
12. Nobles, M. 1987. Testimony to the New York State Governor's Advisory Committee for Black Affairs, Oct. 1, 1987. Women in crisis, New York.
13. Sutton, G. (moderator). 1992. Management of the seropositive prisoner: Medical, ethical and economic perspectives. A roundtable discussion among professionals in correctional health care focusing on HIV/AIDS. Correct Care. 6:4. New York: World Health Communications Inc.
14. New York State Department of Health. 1992. HIV seroprevalence: Semiannual report. Albany, N.Y. (May).
15. Morse, D.L., D.I. Truman, J.P. Hanrahan, et al. 1990. AIDS behind bars: Epidemiology of New York state prison cases, 1980-88. New York State Journal of Medicine, 90:133-38.
16. Greifinger, R., M.D., Chief Medical Officer, New York Department of Correctional Services. December 1992. Interagency communication.
17. Asthma-United States, 1980-1987, MMWR, 1990; 39:493-497.
18. New York State Executive Chamber. Women's Health.
20. Quinn, T.C., D. Glasser, R.O. Cannon and D.L. Matuszak. 1988. Human immunodeficiency virus infection among patients attending clinics for sexually transmitted diseases. New England Journal of Medicine, 318:197-203.
21. New York State Executive Chamber.
22. Ryan, T.A. and J.B. Grassano. 1992. Taking a progressive approach to pregnant offenders. Corrections Today, 54 (6).
23. New York State Correction Law. Section 611.
24. Minkoff, H.L.
26. Resnick, J. and N. Shaw. 1980. Prisoners of their sex: Health problems of incarcerated women. In Prisoner's rights sourcebook.' Theory, litigation and practice, vol. 11, ed. Ira Robbins. New York: Clark Boardman Co., Ltd.
27 Anno, J. 1991. Prison health care: Guidelines for management of an adequate delivery system. Washington, D.C., U.S. Department of Justice, National Institute of Corrections.
28. Moss, S.R. 1986. Women in prison: A case of pervasive neglect. Women and Therapy. 5(2-3):177-185.
30. Ryan, T.A., J.B. Grassano.
31. Butterfield, F.
Phyllis Harrison Ross, M.D., is a nationally recognized expert in forensic psychiatry and correctional medicine, and is president of the medical board, staff associate medical director and director of the Department of Psychiatry and Community Mental Health at Metropolitan Hospital Center in the Bronx, N. Y James E. Lawrence is director of operations for the New York State Commission of Correction. This article was adapted from a chapter written by the authors for Turnstile Justice: Issues in American Corrections, published in 1998 by Prentice-Hall.
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|Title Annotation:||Female Offenders|
|Author:||Ross, Phyllis Harrison; Lawrence, James E.|
|Date:||Dec 1, 1998|
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