Women Prisoners and Health Justice Perspectives, Issues
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Contents
Foreword vii
Preface x
About the Editors xviii
List of Contributors xix
1 The Ongoing Struggle for Ethical Ideals: Justice and Human Rights 1
Anne Davis
2 Social Capital: A Lens for Examining Health of Incarcerated
and Formerly Incarcerated Women 13
Virginia Olesen
3 Challenges Incarcerated Women Face as They Return to
Their Communities: Findings From Life History Interviews 23
Beth Richie
4 Women, Health and Prisons in Australia 45
Judy Parker, Debbie Kilroy and Jonathan Hirst
5 Incarceration of Women in Britain: A Matter of Madness 55
Paul Godin and Kathleen Kendall
6 The Importance of Gender in US Prisons 67
Nancy Stoller
7 Prisons Are Sickening: What Do We Do About It? 77
Karlene Faith
8 Achieving Sustainable Improvement in the Health of Women
in Prisons: The Approach of the WHO Health in Prisons Project 85
Alex Gatherer, Lars Møller and Paul Hayton
9 Standards for Prison Health Care: US and British Approaches 99
Nancy Stoller and Alex Gatherer
10 Ethics for Health Care Providers: Codes as Guidance
for Practice in Prisons 109
Janet Storch and Cindy Peternelj-Taylor
11 Advocacy 117
Donna Willmott
12 Teaching and Learning for Social Transformation 127
Judy Parker, Lisa Reynolds and Donna Willmott
13 Women Prisoners and Health Justice: Challenges and
Recommendations 137
Anastasia Fisher, Diane Hatton and Jane Dorotik
Index 142
Foreword
The proportion of women in prison systems throughout the world varies bet-
ween 2% and 9%, with only 12 jurisdictions having a higher proportion.1 These
figures do not mean that the total number of women in prison is small. Indeed,
in many jurisdictions recent increases in the number of women in prison has
exceeded the increase in male prisoners. It is estimated that there are over half
a million women and children in prison, either sentenced or awaiting trial. Of
these, one-third is in the US.
One consequence of the proportional imbalance of the sexes is that prisons
and prison systems tend to be organized to meet the needs and requirements of
male prisoners. This applies to architecture, to security and to all other facilities.
There is a recurring tendency that any special provision for women prisoners will
be something that is added on to the standard provision for men. This is despite
the fact that the profile of women prisoners is very different from that of male
prisoners, and particular attention should be given to their special needs.
Most women will have been imprisoned for non-violent property offenses.
If their crime has been a violent one, the victim is likely to have been someone
close to them. Many women prisoners will have suffered frequent physical or
sexual abuse. They will often have a variety of untreated health problems. In
addition, the consequences of imprisonment and its effect on their lives may
be very different for women. A large number will be single parents, often with
dependent children. When a man is sent to prison, his partner may well do all
in her power to keep the family together. When a woman goes to prison, there
is less likelihood that her partner will manage to do the same.
In a number of countries tough anti-drug legislation has had a significant
effect on the numbers of women in prison. Another feature of this and similar
changes has been an increase in the proportion of foreign national prisoners
who now form a large percentage of women prisoners in some countries. All of
these factors mean that prison authorities need to pay special attention to the
way women prisoners are treated and the facilities that are provided for them.
vii
viii FOREWORD
This is especially so in terms of their health needs.
The health profile of prisoners as a whole is poor. This is not surprising, given
the fact that in most jurisdictions prisoners are drawn largely from marginal-
ized groups. Many will have untreated health conditions. A high proportion of
them will be addicted to one or more drugs of abuse, with the added possibility
that they may suffer from infectious hepatitis, tuberculosis or HIV. The incid-
ence of mental health problems among prisoners is very high. If that is their
condition when they enter prison, the environment in which they then live is
likely to exacerbate their problems. In many instances living conditions may be
badly overcrowded, sanitary arrangements may be poor, diet will be inadequate,
there will be limited access to fresh air and exercise, and health provision will
be unsatisfactory. For women in prison, many of these problems will be writ
even larger.
This book, edited by Diane Hatton and Anastasia Fisher, fills a major gap in
the literature on two counts: it is about women prisoners, and it is about their
entitlement to proper health care. The editors have gathered a knowledgeable and
experienced group of experts from around the world to contribute chapters on key
issues on this topic. This volume is likely to become a classic reference text.
This book should be read by all those who are in any way involved in the
imprisonment of women. But it is not only a book for practitioners, academics
and prison policy makers. It also needs to be read by those involved in the world
of health policy and health delivery and its lessons taken on board by them.
The women who are described in this volume are a problematic group. Their
health problems are complex and often not easily resolved. They may not always
be grateful for help when it is offered. It is too easy for health professionals to
ignore their problems, to put them into a category marked “too difficult.” All
health professionals should bear in mind the Oath of Athens passed in 1979 by
the International Council of Prison Medical Services which pledged “in keeping
with the spirit of the Oath of Hippocrates . . . we shall endeavor to provide the
best possible health care for those who are incarcerated in prisons for whatever
reasons, without prejudice and within our respective professional ethics. We
recognize the right of the incarcerated individuals to receive the best possible
health care.”2
That commitment applies particularly to women who are in prison. This
book serves to reinforce that pledge.
Andrew Coyle
Professor of Prison Studies
School of Law
King’s College
University of London
June 2009
FOREWORD ix
REFERENCES
1 Walmsley R. World Female Imprisonment List. London: International Centre for Prison
Studies; 2006.
2 Coyle A. A Human Rights Approach to Prison Management. London: International Centre
for Prison Studies; 2002. p. 57. Available at: www.kcl.ac.uk/depsta/law/research/icps/
downloads/human_rights_prison_management.pdf (accessed February 28, 2009).
Preface
The past three decades have witnessed an unprecedented increase in the world-
wide prison population that includes a burgeoning number of women. The US
leads this trend with 25% of the world’s prisoners, in spite of having only 5%
of the world’s population.1 The US confines more than one in every 100 adults
in a jail or prison2 and although men are more likely to be incarcerated, the
number of women prisoners has increased at a faster pace. In 2008, African-
American women from age 35 to 39 reached the 1-in-100 mark.2 The US patterns
of incarceration, its disproportionately high convictions of the poor and racial/
ethnic minorities, as well as its deteriorating prison conditions are found in
other countries, including Canada, Australia, and the UK.3
Incarceration severely affects the health and well-being of women, and dis-
proportionately impacts women of color who are incarcerated at substantially
higher rates than their white counterparts.4 When removed from their commu-
nities, incarcerated women are placed in jails and prisons where infectious and
chronic diseases are frequently prevalent, and medical neglect exists in spite
of the national and international documents that clearly define standards for
health care. Eventually most women prisoners return to communities where
they encounter difficulty accessing needed services, especially substance abuse
and other mental health treatment. They also find limited opportunities for
job training and employment, lack of adequate housing, and other circum-
stances that impede successful reentry and put them at substantial risk for
recidivism.5
The scope of this international problem remains largely hidden from health
professionals and policy makers. Although the majority of women prisoners
are convicted of non-violent, drug-related crimes, the political discourse about
this enormous increase in women’s imprisonment often centers on public
safety, and health is given little acknowledgement by politicians advancing their
careers with tough-on-crime approaches.6 This book analyzes how incarcera-
tion severely limits women’s opportunities, damaging their health and that of
x
PREFACE xi
their families and communities. The book also examines how imprisonment
further complicates the health disparities women prisoners experience as a con-
sequence of gender, race, and class, for typically they bear the burden of being
poor, being female, being women of color, and having a history of a criminal
conviction.7 They commonly suffer multiple, persistent physical, mental, and
social health problems.4,8–13 Their pregnancy rates are higher than their cohorts
in the general population and they often report histories of violence as children
and as adults.14,15 Compared with male prisoners, they are more likely to have
been homeless, report drug charges at arrest, and be parents.16 Research also
indicates that during the first 12 months after release from prison, women’s
risk for suicide is higher than the general population and higher than recently
released men.17
However, we have not organized this book around specific diseases or health
problems as the reader can find these comprehensive accounts in the literature.
We have taken a different approach by focusing on perspectives for examining
health among women prisoners, including human rights and social capital. We
consider specific circumstances related to their health and health care access,
such as race, gender, class, and prison environments. We emphasize strategies
for moving from knowledge to action that address health promotion, standards,
codes of ethics, advocacy, and education.
AIM OF THE BOOK
The aim of this edited book is to address the gap in knowledge about the
health of women prisoners and it represents the outcome of a meeting orga-
nized by the editors and supported by the Rockefeller Foundation at their
Study and Conference Center in Bellagio, Italy. During that meeting, our
group discussed the ideas in this book and represented various viewpoints
as advocates, criminologists, feminists, former prisoners, nurses, physicians,
public health professionals, social workers, and sociologists. We began this
effort with four countries – Australia, Canada, the UK and the US – because we
speak a common language and our countries have similar legal traditions. We
hope that future work will bring additional countries and perspectives to this
discourse as the imprisonment of women has become a transnational, global
phenomenon.18
OVERVIEW OF THE BOOK
In this book we use the term “health” broadly, as does the World Health
Organization (WHO), to include “physical, mental, and social well being and
not merely the absence of disease or infirmity.”19 We also address women pris-
oners in a broad manner by considering not only those incarcerated but also
xii PREFACE
those with a history of incarceration, such as women attempting to reenter the
community after release from prison.
In Chapter 1, Anne Davis reviews the ethical and legal principle of justice,
the conceptual frame for human rights. She explores the philosophical and
historical support for human rights and considers the interaction between
human rights and health. Davis asks health professionals and others aware of
the socio-economic and political human rights issues surrounding the increased
imprisonment of women to consider what model of justice benefits society and
individuals. The values of justice and rights for all humans are foundational to
this book’s assumptions about what constitutes health problems for women
prisoners and what actions to take in response.
In Chapter 2, Virginia Olesen situates the individual woman prisoner in a
social context that allows us to think about how women secure benefits by virtue
of their membership in social networks and other social structures. She explores
how these networks assist or hinder women in accessing resources – both inside
and outside prison. When thinking about reentry, she proposes exploration of
those networks that will broaden the opportunities for successful reintegration
to communities.
In Chapter 3, Beth Richie’s seminal research article describes the challenges
that incarcerated women face as they return to their communities from jail
or prison. Richie’s chapter provides thick description of social networks and
structures that are critical for women, their children, and other family members.
She points to the urgent need for social reform and argues that the challenges
women face must be met by a more thoughtful criminal justice policy that
requires reinvestment in low-income communities to reduce recidivism.
In Chapter 4, Judy Parker, Debbie Kilroy and Jonathan Hirst examine pat-
terns of women’s incarceration in Australia and focus particular attention on
forensic mental health services as well as Aboriginal and Torres Strait Islander
women within the criminal justice system. They demonstrate the health diffi-
culties experienced and argue for a shift from prison-based to community-based
care with provision of adequate social and health services. They discuss the
mounting evidence that the prison environment exacerbates disadvantage and
discrimination. They recommend strategies for community-based programs
aimed at healing the wounds suffered by women who have been victims of an
uncaring society.
In Chapter 5, Paul Godin and Kathleen Kendall also analyze the harmful effects
of incarceration, focusing on the history of British women’s prisons and paying
particular attention to mental health. They argue that programs for women pris-
oners often focus on the mental pathology of individual women rather than on
the numerous social processes that contribute to incarceration in the first place,
such as social marginalization, policing, and sentencing practices. They sup-
port the implementation of gender-responsive programs for women prisoners.
PREFACE xiii
In Chapter 6, Nancy Stoller’s commentary explores ways that gender is man-
aged through prison policies and practices. Considering racism and ethnicity,
as well as gender, she examines how women’s prison experiences cannot be
understood through a lens that focuses primarily on men. Stoller describes how
women prisoners who become ill or suffer unintended or intended trauma are
already in a hostile environment where their identities, former lives, families,
affectional ties, and self-agency are under attack. She argues that the intricate
systems of racism and sexism present barriers to the delivery of jail and prison
health care, and she discusses the discriminatory practices former prisoners
encounter upon release.
In Chapter 7, Karlene Faith’s commentary argues that prisons are antithetical
to women’s health. She presents data from interviews conducted with women
prisoners in the US and Canada that illustrate the damaging effects of incarcera-
tion on health. She advocates a transformative model of justice that challenges
a need for prisons in a civilized society. Like Anne Davis (Chapter 1), she
acknowledges the physical, emotional, and mental harm to women prisoners
as a human rights abuse. She proposes the ideals of transformative justice as a
new way to think about the kind of society we want to inhabit.
In Chapter 8, Alex Gatherer, Lars Møller and Paul Hayton take a public
health point of view and argue that one of the most urgent tasks of prisons is
to improve the health, resilience, and well-being of all those in compulsory
detention, especially women. They describe how this is in the women’s best
interests, and the interests of their families and others. They emphasize that
the health of women prisoners is important to public health as a whole. Their
chapter discusses the WHO Health in Prisons Project (HIPP) that was launched
in 1995 in eight European countries. HIPP offers a model for the development
of collaborative, multinational, and multidisciplinary relationships that address
the challenges of prison health care.
In Chapter 9, Nancy Stoller and Alex Gatherer examine accreditation, stan-
dards, monitoring, professionalization, and community-based care provision
as means of improving prison health care. They offer comparisons between the
US and English systems that highlight the approaches taken in the two coun-
tries in prison health care and community-based care. The differences between
the US and England demonstrate the significance of having one national health
care system to provide a community standard of care inside prisons instead of
a fragmented collection of services.
In Chapter 10, Janet Storch and Cindy Peternelj-Taylor borrow extensively
from the Canadian Nurses Association (CNA) Code of Ethics for Registered
Nurses (2008) to illustrate how codes can guide health providers’ actions in
practice. The chapter includes discussion of the dual responsibilities – control
and care – health care professionals encounter in prisons. While recognizing
prisons as unhealthy and detrimental places for all people, these authors argue
xiv PREFACE
that health professionals can do a great deal to offer respectful health-promoting
care, to protect prisoners from research abuse, and to advocate for alternatives
to imprisonment.
In Chapter 11, Donna Willmott builds on the ethical obligation for advocacy
by exploring specific ways that health professionals may fulfill this obligation.
She describes advocating for individual patient-prisoners, supporting the efforts
of prisoners to advocate for themselves, and working with community-based
organizations to ensure the rights and dignity of patient-prisoners through pub-
lic education and policy change. Using examples of organizations in Australia,
Canada, and the US, she demonstrates how collaboration between health pro-
viders, prisoners’ rights advocates, prisoners and former prisoners can encourage
policy change to lessen the negative impact of incarceration on individuals,
families, and communities.
In Chapter 12, Judy Parker, Lisa Reynolds and Donna Willmott bring
together many issues addressed in previous chapters and focus on the educa-
tional needs of professionals, policy makers, community workers, and members
of the public concerned about the health status of incarcerated women. They
argue that education can play a crucial role in shifting attitudes and values, and
support curricula that broaden individuals’ horizons and challenge stereotypi-
cal and negative ways of thinking about women in prison. They also recognize
the importance of examining the socio-political and structural reasons that
lie behind incarceration. They offer an emancipatory approach to curriculum
development as a tool to improve the health and well-being of incarcerated
women.
In Chapter 13, Anastasia Fisher, Diane Hatton and Jane Dorotik summarize
the major points of the book and make recommendations for action. The latter
include using jails and prisons sparingly, especially for non-violent offenses;
replacing incarceration with community alternatives such as drug, mental
health, and homeless courts; improving prison health care and programs; and
supporting the conduct of ethical research with prisoners. Using California as an
example, the chapter summarizes the problems of delivering health care when
there is mass incarceration. The chapter concludes by arguing that societies have
a choice: they can continue to punish mass numbers of individuals or reinvest
in their communities and their children. This reinvestment includes tackling
the problems of inequity, discrimination, and the paralyzing effects of poverty.
Only then can health justice be achieved.
PREFACE xv
SUMMARY
Imprisonment impacts women’s physical, mental, and social health. Taking
the perspective of women as creators of social capital, this book demonstrates
how imprisonment further complicates the health disparities women prisoners
already experience as a consequence of gender, race, and class. It also considers
the collateral damage to families and communities as a consequence of women’s
imprisonment.1,20 Estimates suggest, for example, that almost 70% of the women
prisoners in the US are mothers. When they are incarcerated, their children are
left behind with little protection or hope; these children are often forced into
foster care and become vulnerable to the psychosocial problems that entails.20
This book offers different views on whether prison health care can be
improved. Some say that prisons can and should be health-promoting settings;
others suggest this is not possible. Our intention is to capture these various
perspectives and acknowledge their tension. In spite of their differences, the con-
tributors to this volume come from a human rights perspective, acknowledging
that women have a right to health care, both in and out of prison. Thus, this
collection of essays represents an effort to address and advocate for the health
of women prisoners from a health justice perspective, which the editors under-
stand as the fair and equal distribution of health resources in communities as
well as in prisons. We use the term here to capture the idea that for health to
be a possibility, inequities, discrimination, and the paralyzing effects of poverty
must be addressed by societies around the world.
The physical, mental, and social conditions experienced by women prison-
ers, their minor children, their families, and their communities have not been
adequately acknowledged or addressed by society as a whole or by those seg-
ments of society that could make a difference in their lives. Over our careers we
have worked with persons who have mental illnesses, substance use disorders,
and histories of homelessness. We have witnessed a shift in the location of
these populations from traditional settings such as shelters, community health
clinics, and psychiatric hospitals, to jails and prisons. In our communities, the
local jails have now become the largest providers of mental health services.
The health care system in our overcrowded California prisons has been placed
under a federal receiver because its inadequate medical care violated the US
Constitution’s Eighth Amendment that forbids cruel and unusual punishment
of incarcerated persons.21
We have presented this topic to medical residents, students in public health,
nursing, social science, and liberal arts, custody staff, as well as international,
national, regional, and local health professional groups. These presentations
have illuminated the need for increased awareness about the global scope of
the problems facing women prisoners and the health professionals responsible
for their care. We hope this work will generate an interest among physicians,
nurses, social workers, public health workers, health law professionals, policy
xvi PREFACE
makers, and other interested advocates to develop and implement strategies
that will reduce avoidable and unfair differences in the health status of women
prisoners.
Diane C Hatton
Anastasia A Fisher
June 2009
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4 Braithwaite RL, Treadwell HM, Arriola KR. Health disparities and incarcerated
women: a population ignored. Am J Public Health. 2005; 95(10): 1679–81.
5 Freudenberg N, Daniels J, Crum M, et al. Coming home from jail: the social and
health consequences of community reentry for women, male adolescents, and their
families and communities. Am J Public Health. 2005; 95(10): 1725–36.
6 Walmsley R. Prison planet. Foreign Policy. 2007; 160(May/Jun): 30–1.
7 Freudenberg N. Adverse effects of US jail and prison policies on the health and well-
being of women of color. Am J Public Health. 2002; 92(12): 1895–9.
8 Stoller N. Improving Access to Health Care for California’s Women Prisoners. Berkeley,
CA: California Policy Research Center, University of California; 2001. Available at:
http://cpac.berkeley.edu/documents/stollerpaper.pdf (accessed May 24, 2009).
9 Hatton DC, Kleffel D, Fisher AA. Prisoners’ perspectives of health problems and
healthcare in a US women’s jail. Women and Health. 2006; 44(1): 119–36.
10 National Commission on Correctional Health Care. The Health Status of Soon-To-Be-
Released Inmates: a report to congress. Available at: www.ncchc.org/pubs/pubs_stbr.
html (accessed November 5, 2008).
11 Federal Bureau of Prisons. Management of Methicillin-Resistant Staphylococcus Aureus
(MRSA) Infections. Washington, DC: Department of Justice; 2005. Available at: www.
bop.gov/news/PDFs/mrsa.pdf (accessed May 24, 2009).
12 Willmott D, van Olphen J. Challenging the health impacts of incarceration: the
role for community health workers. Californian J Health Promot. 2005; 3(2): 38–48.
Available at: www.csuchico.edu/cjhp/3/2/38-48-willmott.pdf (accessed November 5,
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13 Braithwaite RL, Arriola KJ, Newkirk C. Health Issues Among Incarcerated Women. New
Brunswick, NJ: Rutgers University Press; 2006.
14 Fogel CI, Belyea M. Psychological risk factors in pregnant inmates. A challenge for
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15 Richie BE, Freudenberg N, Page J. Reintegrating women leaving jail into urban
PREFACE xvii
communities: a description of a model program. J Urban Health. 2001; 78(2):
290–303.
16 Freudenberg N, Moseley J, Labriola M, et al. Comparison of health and social
characteristics of people leaving New York City jails by age, gender, and race/ethni-
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17 Pratt D, Piper M, Appleby L, et al. Suicide in recently released prisoners: a population-
based cohort study. Lancet. 2006; 368(9530): 119–23.
18 Sudbury J, editor. Global Lockdown: race, gender, and the prison-industrial complex. New
York, NY: Routledge; 2005.
19 World Health Organization. WHO Definition of Health. 1948. Available at: www.who.
int/about/definition/en/print.html (accessed November 5, 2008).
20 Golden R. War on the Family: mothers in prison and the families they leave behind. New
York, NY: Routledge; 2005.
21 California Prison Health Care Services. California Prison Health Care Receivership Corp.
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