Position Statements

Women's Health Care in Correctional Settings

Introduction
Women are the fastest growing segment of the U.S. incarcerated population, increasing an average of 5% each year between 1995 and 2003. Incarcerated women report histories of alcohol and drug abuse, sexually transmitted disease, and mental illness. They are more likely than men to have been under the influence of drugs at the time of their crime; moreover, they may have committed the offense to raise money to buy drugs (CASA, 1996). High rates of gonorrhea, chlamydia, and trichomoniasis also have been found among incarcerated women (Hammett, Harmon, & Rhodes, 2000; Shuter, 2000). Further, incarcerated women have higher rates of depression than incarcerated men or the general community (Gunter, 2004). As a result, incarcerated women utilize health care services much more than men, creating unique challenges for health services management. This position statement is intended to guide the correctional administrator in the management of women’s health care.

Background

Gynecological. Research on the provision of gynecological services for women in prison settings has consistently indicated that current services are inadequate (Weatherhead, 2003). Gynecological exams are not performed upon admission to prison, nor are they routinely provided on an annual basis. Appropriate initial screening questions about a woman’s gynecologic history often are not asked. Further, many jails and prisons lack health providers who are trained in obstetrics and gynecology, which leads to inadequate and inappropriate gynecologic care. As a result, women in prison are at risk for having some diseases, such as breast and ovarian cancer, or abnormal Pap smears go undetected.

Pregnancy. Owing to their past medical histories, incarcerated women tend to have complicated and high-risk pregnancies. At the time of their arrest and incarceration, many pregnant inmates lack prenatal care and need considerable support to improve the clinical outcomes of their pregnancies. For example, fetal alcohol syndrome disorder (FASD) creates psychological, neurological, and physical impairments (CASA, 1996). Pregnant inmates have high levels of psychological distress, yet often do not receive counseling and support services. Likewise, screenings for postpartum physical and psychiatric complications often are not performed.

Parenting Services. Female inmates do not receive appropriate parenting and child custody services. Entering a correctional facility is very stressful, but for women with children it is even more intense because of the separation from their children. The Bureau of Justice Statistics (2000) found high rates of incarcerated women with young children, ranging from 59% in federal prisons to 70% in local jails. It has been reported that more than two-thirds of women in prison had at least one child under the age of 18 years (BJS, 2000). Additionally, in 1997, 5% of the women entering prison were pregnant (BJS, 2000).

Sexual and Physical Abuse. It has been estimated that from 43% to 57% of state and federal women prisoners have been physically or sexually abused at some time (Harlow, 1999; Greenfeld & Snell, 1999; Snell & Morton, 1994). Such abuse can lead to lifelong psychological problems such as depressive disorders, stress disorders, anxiety disorders, learning problems, substance abuse (with its attendant physical health problems), and behavioral disorders of violence and impulsivity. Further, being victimized can have serious consequences. One-third of all female inmates serving time for a violent crime had victimized a relative or intimate, and of these inmates, two-thirds had victimized either their spouse or a family member such as a sibling or even their own child (Snell & Morton). Women incarcerated for a violent offense were the most likely to report having experienced physical or sexual abuse; and among women incarcerated for a violent crime, those who reported having been abused were more likely than other inmates to have victimized a relative or intimate (Greenfeld & Minor-Harper, 1990).

Alcohol and Drug Abuse. A history of problems with alcohol and/or other drugs is another common complaint of women entering prison. A U.S. Department of Justice (1999) study revealed that over 40% of female prisoners were under the influence of drugs at the time of their offense. Because of this abuse, many women prisoners are at much greater risk of becoming HIV positive from having had unprotected sex or having used dirty needles. Drug counseling, by itself, is not enough: The track record shows that addicts almost always relapse.

Sexually Transmitted Disease. Owing to their risky behaviors with alcohol, drug abuse, and unprotected sex, women entering correctional facilities have high rates of sexually transmitted disease (STD). Rich and his colleagues (2001) found that 49% of Rhode Island women with infectious syphilis had been incarcerated at some point between 1992 and 1998. High rates of gonorrhea, chlamydia, and trichomoniasis also have been found among incarcerated women (Hammett, Harmon, & Rhodes, 2000; Shuter, 2000).

Mental Health. Studies on male offenders with mental illness in Western nation prisons have consistently demonstrated high prevalence of personality disorders (about 65%), major depression (on average 10%), and psychosis (about 4%). The prevalence of women offenders with mental illness parallels that of males. However, women offenders are more likely to have histories of dual diagnoses (Abram, Teplin, McClelland, & Dulcan, 2003; Abram, Teplin, & McClelland, 2003; Hartwell, 2004).

Aging. Many prisons housing relatively large percentages of older prisoners have not implemented sufficient programming for the elderly (Reviere & Young, 2004). In fact, many prisons may be failing to recognize and prepare for the specialized physical, social, and psychological needs of the older female inmate (Reviere & Young).

Nutrition and Diet. Correctional institutions should ensure that women between the ages of 23 and 50 consume 2,200 calories a day to maintain weight (Food and Nutrition Board of the National Research Council). The average women’s diet should contain no more than 300 milligrams of cholesterol per day to keep cholesterol levels in the “good” range (National Cholesterol Education Program of the National Heart, Lung, and Blood Institute). Women’s diets should include 20 to 30 grams of fiber per day (National Cancer Institute). Since women lose 15 to 20 milligrams of iron each month during menstruation, they should take 15 milligrams of iron supplements a day. Without sufficient iron replacement, symptoms of pallor, fatigue, and headaches could arise.

Standards
NCCHC recognizes the need to view women as a special population and to provide appropriate treatment. The Standards for Health Services (the basis of NCCHC’s accreditation program for jails, prisons, and juvenile detention and confinement facilities) contain several standards that impact women’s health care, including the following:

• Receiving Screening (J/P/Y-E-02) suggests inquiry into current gynecological problems and pregnancy for women and female adolescents;

• Health Assessment (J/P/Y-E-04) recommends that pelvic examinations and Pap smears be considered but they are not mandated, except in prisons;

• Nutrition and Medical Diets (J/P/Y-F-02) addresses the issue of nutritional intake, as does Appendix H Medical Diets; and

• Pregnancy Counseling (J/P/Y-G-10) specifies that comprehensive counseling and assistance are given to pregnant inmates in keeping with their express desires in planning for their unborn children, whether they desire abortion, adoptive service, or to keep the child.

Position Statement
NCCHC recognizes that the number of female inmates is large and growing annually, presenting unique and increasing problems for health services in correctional facilities. Therefore, NCCHC recommends the following:

1. Correctional institutions should be required to meet recognized community standards for women’s services as promoted by standards set by NCCHC.

2. Correctional health services and women’s advocacy groups should collaborate to provide leadership for the development of policies and procedures that address women’s special health care needs in corrections.

3. Correctional institutions should implement intake procedures that include histories on menstrual cycle, pregnancies, gynecologic problems, and nutritional intake (by conducting a nutritional assessment) (Anno, 2001).

4. Comprehensive services for women’s unique health problems should be provided in prisons, jails, and juvenile detention and confinement facilities:

A. Considering women’s special reproductive health needs, the frequency of repeating certain tests, exams, and procedures (e.g., Pap smears, mammograms) should be based on guidelines established by professional groups such as the American Cancer Society and the American College of Obstetricians and Gynecologists, and should take into account age and risk factors of the female correctional population (Anno, 2001).

B. Considering the high levels of victimization (sexual and physical) among the female inmate population, and considering the circumstances of incarceration of violent female offenders (i.e., many have committed interpersonal altercation violence against a family member or intimate), counseling to resolve issues of victimization and perpetration of violence against intimates (such as conflict resolution skills or parenting skills) should be available.

C. Considering the large number of incarcerated women who have dependent children, counseling on parenting and child custody issues should be available.

D. Considering the high rates of depression women report upon incarceration, counseling should be available to address this issue.

E. Considering the high rates of alcohol and/or drug problems women report upon incarceration, counseling should be available to address this issue.

F. Correctional institutions should provide intake examinations that include a breast exam and, depending on the female’s age, sexual history, and past medical history, also a pelvic exam, Pap smear, and baseline mammogram (Anno, 2001).

G. Correctional institutions should provide laboratory tests to detect sexually transmitted diseases including gonorrhea, syphilis, and chlamydia for all females, especially since many are asymptomatic for STDs. Females also should receive a pregnancy test on admission to correctional facilities (Anno, 2001). Further, since new research indicates that pregnant women who are infected with HIV are less likely to transmit the virus to their newborn if they are treated with AZT during pregnancy, women should be educated about this finding and encouraged to be tested for HIV if they are pregnant.

H. Considering that many female adolescents who enter the juvenile justice system have unique educational needs, special attention should be given to counseling and habilitation in this area.

5. Correctional institutions should provide pre- and postrelease services for women reentering the community. Strong partnerships are encouraged between public health, community, public assistance, and correctional agencies. Programming such as employment and vocational training, health education, and parenting education also should be available.

Adopted by the National Commission on Correctional Health Care Board of Directors
September 25, 1994
Revised: October 9, 2005

References

Abram, K. M., Teplin, L. A., & McClelland, G. M. (2003). Comorbidity of severe psychiatric disorders and substance use disorders among women in jail. American Journal of Psychiatry,
160(5),1007-1010.

Abram, K. M., Teplin, L. A., McClelland, G. M., & Dulcan, M. K. (2003). Comorbid psychiatric disorders in youth in juvenile detention. Archives in General Psychiatry, 60(11), 1097- 1108.

Anno, B. J. (2001). Correctional health care: Guidelines for the management of an adequate delivery system, 2nd ed. Chicago: National Commission on Correctional Health Care.

Greenfeld, L. A., & Snell, T. L. (1999). Women offenders (NCJ 175688). Washington, DC: U.S. Department of Justice.

Gunter, T. D. (2004). Incarcerated women and depression: A primer for the primary care provider. Journal of the American Medical Women’s Association, 59(2), 107-112.

Hammett, T. M., Harmon, M. P., & Rhodes, W. (2002). The burden of infectious disease among inmates of and releasees from correctional facilities. In The health status of soon-to-be-released inmates: A report to Congress: Vol. II. Chicago: National Commission on Correctional Health Care.

Harlow, C. W. (1999). Prior abuse reported by inmates and probationers (NCJ 172879). Washington, DC: U.S. Department of Justice.

Hartwell, S. W. (2004). Comparison of offenders with mental illness only and offenders with dual diagnoses. Psychiatric Services, 55(2), 145-150.

Mullings, J. L., Hartley, D. J., & Marquart, J. W. (2004). Exploring the relationship between alcohol use, childhood maltreatment, and treatment needs among female prisoners. Substance Use & Misuse, 39(2), 277-305.

Reviere, R., & Young, V. D. (2004). Aging behind bars: Health care for older female inmates. Journal on Women and Aging, 16(1-2), 55-69.

Rich, J. D., Hou, J. C., Charuvastra, A., Towe, C. W., Lally, M., Spaulding, A., Bandy, U., Donnelly, E. F., & Rompalo, A. (2001). Risk factors for syphilis among incarcerated women in Rhode Island. AIDS Patient Care and STDS, 15(11), 581-585.

Shuter, J. (2002). Public health opportunities for the correctional intervention on inmates with communicable disease. In The health status of soon-to-be-released inmates: A report to Congress: Vol. II. Chicago: National Commission on Correctional Health Care.

Snell, T. L., & Morton, D. C. (1994). Women in prison: Survey of state prison inmates, 1991 (NCJ 145321). Washington, DC: U.S. Department of Justice.

Weatherhead, K. (2003). Cruel but not unusual punishment: The failure to provide adequate medical treatment to female prisoners in the United States. Health Matrix: Journal of Law and Medicine, 13(2), 429-472.

Zlotnick, C., Najavits, L. M., Rohsenow, D. J., & Johnson, D. M. (2003). A cognitive-behavioral treatment for incarcerated women with substance abuse disorder and posttraumatic stress disorder: Findings from a pilot study. Journal of Substance Abuse Treatment, 25, 99-105.