Threats to Women’s Health in Prisons and Jails

People incarcerated in women’s facilities represent the fastest growing segment of the US carceral population, with approximately 190 600 incarcerated and 808 700 under probation or parole.¹ Most of these women are confined in jails followed by prisons, with women from racial and ethnic minority groups experiencing the highest rates of incarceration. Compared with men, women serve proportionally more sentences for nonviolent offenses and have greater difficulty affording bail to avoid pretrial detention.

Women who are incarcerated are more likely than nonincarcerated persons to have faced physical, emotional, or sexual abuse before imprisonment. Compared with men, women experience higher rates of chronic medical and psychiatric conditions and higher mortality rates in jails, increasingly by suicide.² Many women lack sufficient menstrual products during incarceration and report needing to barter for these basic supplies.³ Most imprisoned women are mothers and primary caretakers to minors, with detainment resulting in family separation and potential foster care placement of children, causing intergenerational loss for communities.

Yet, women have been left behind in efforts to slow carceral growth. Women’s prison populations have grown 834% over the past 40 years, double the pace of men’sprisons.¹ Reasons include increasing criminalization of women’s responses to gender-based violence, including intimate partner violence and survival efforts through sex work, fewer diversion programs for women allowing community programming in lieu of prison time, and higher rates of disciplinary action while incarcerated, which can prolong sentences.

Women experience both interpersonal and structural violence within carceral settings. Herein, we focus on 5 attacks on the health of incarcerated women to examine carceral control over women’s bodies and opportunities for reform.

Forced Sterilization and Coerced Contraception

The carceral system frequently exerts control over women’s reproductive autonomy. The most egregious examples are forced sterilization through tubal ligation, salpingectomy, oophorectomy, hysterectomy, and coerced contraception via the administration of long-acting contraceptive medications.

In a recent example of forced sterilization, of 144 tubal ligations performed on women incarcerated in California between 2005 and 2013, over 25% were completed without signed consent forms.⁴ Most ligations were performed on Black and Latine women with low literacy rates, though lack of documentation of patient education and counseling casts doubt on informed consent for all sterilizations during this period.

Carceral control over reproductive autonomy may also arise through coerced contraception as a condition of reduced sentencing. In 2017, a Tennessee judge offered a 30-day reduction in jail time to women who received an etonogestrel contraceptive implant. Although the order ultimately was rescinded, it offered a glimpse into coercive consent, in which women were forced to choose between community freedom or reproductive freedom.

Sexual Violence

Prison rape is a crime of power, resulting in retaliatory violence, impaired mental health, substance use, and sexually transmitted infections. “Inmate-on-inmate” sexual violence is 4-times higher for women (212 per 1000) than for men.⁵ Correctional employees control incarcerated persons’ lives, so there is no scenario in which an incarcerated individual can provide sexual consent. Yet, just this year, a federal women’s facility in California was closed for widespread sexual abuse and retaliation by its officers and warden.

In 2003, the Prison Rape Elimination Act (PREA) codified standards for prevention and response to rape in carceral facilities, including mandated reporting of sexual assault, and required staff training. The PREA has been met with mixed success; women reported improved support, empowerment, and awareness of sexual violence but also weaponization of the policy through false allegations by incarcerated persons and staff as a means of bullying or punishment.

Impaired Access to Desired Reproductive Care

Access to contraception and abortion is important for people with childbearing capacity who are sexually active while incarcerated or following release, when barriers to community medical care are common. Many incarcerated women face an unmet need for contraception due to lack of access to trained clinicians, low health literacy, and variable jurisdictional regulations. Uptake of contraception is more likely when offered during incarceration than when offered following release,⁶ so carceral facilities should advance policies to counsel women on reversible contraceptive methods.

Access to abortion varies widely by jurisdiction, even in supportive states, and most facilities exert restrictive policies through explicit prohibition, trimester limitations, or self-payment requirements.⁷ This results in individuals carrying pregnancies, sometimes undesired, in an environment with limited prenatal care. The 2022 Dobbs v Jackson Women’s Health Organization ruling removed the constitutional right to abortion. Dissimilar to individuals in the community, those detained in states with increasing abortion restrictions cannot seek access in other states or obtain medication abortion through telemedicine.

Shackling During Pregnancy

Between 3% and 5% of people are pregnant when they enter carceral facilities; approximately 1400 children are born to incarcerated persons yearly.⁸ These pregnancies are frequently compromised by lack of prenatal care, poor nutrition, sexually transmitted infections, history of partner violence, and untreated health conditions. Compared with the general population, incarcerated women have a higher risk for preterm delivery and low-birth-weight infants.⁹

Shackling of incarcerated patients during hospitalization for childbirth was pervasive until the 2018 First Step Act banned restraint of pregnant persons in federal custody through their postpartum recovery. In 1999, Illinois became the first state to restrict shackling pregnant patients, and through growing community activism, frequently led by individuals who had experienced shackling, 40 states now prohibit or limit such restraint. Some states ban shackling during transport, childbirth, and post partum, while others limit use only during birth. Despite prohibitions, the practice persists, such that in 2019, New York City settled a case of an incarcerated woman shackled during childbirth despite state law and clinician objections.

Barriers to Gender Self-Determination

Gender minority individuals experience among the highest rates of incarceration, though data on the health of incarcerated transgender people remains limited. In the community, transgender people experience stigma, sexual violence, barriers to housing, and forced participation in street economies. These experiences are amplified in carceral settings. Sexual assault is 13 times more prevalent among incarcerated transgender people,¹⁰ and it is common for carceral authorities to house transgender individuals in restricted (ie, solitary confinement) housing units.

The PREA requires that housing determinations for transgender or nonbinary people be assessed on an individual basis; such ambiguity provides carceral agencies broad discretion. Many prisons require transgender people to have undergone gender-affirming treatment and surgery before placement in a facility that aligns with their identity, yet access to gender-affirming care is often limited or requires long wait times. While the culture of men’s and women’s prisons differ, both can be homophobic and transphobic environments. In states that allow placement based on gender identity, use of solitary confinement and violence against transgender women, coupled with safety concerns and reports of violence made by cis-gender women, demonstrate the complexity of offering gender-affirmative housing in the carceral context.

Conclusions

Women enter the criminal-legal system with diminished societal power and often with a history of trauma and poorly treated health conditions. While incarcerated, a pattern of control and violence toward women’s bodies pervades. With the rapid growth of women in the carceral system, clinicians, public health experts, and legislators should focus on improving access to health care, codifying informed consent practices, and ensuring that women receive ethically grounded and trauma-informed care within a system traditionally hostile to their bodies. Public policy should prioritize efforts to reduce the number of incarcerated women, while also creating community systems of support and strength-building as alternatives to incarceration that keep women out of prisons and jails altogether.