Health Disparities and Incarcerated Women: A Population Ignored

I am an invisible man. No, I am not a spook like those who haunted Edgar Allan Poe; nor am I one of your Hollywood-movie ectoplasms. I am a man of substance, of flesh and bone, fiber and liquids—and I might even be said to possess a mind. I am invisible, understand, simply because people refuse to see me.… When they approach me they see only my surroundings, themselves, or figments of their imagination—indeed, everything and anything except me.

Ralph Ellison, Invisible Man

Although Ralph Ellison’s Invisible Man (1952) was written to chronicle the plight of one who was both Black and American, the quotation above might also describe the feelings of incarcerated populations, particularly incarcerated women, in the United States. Incarcerated women are largely African American; thus, many of them bear the quadruple burden of their race/ethnicity, class, gender, and status as a criminal offender. That being Black, being female, being poor, and being a criminal offender confers serious health risks is clear. Because incarcerated women are “invisible,” there has been little in the way of research and policy development that would advance their health status. Thus it is no surprise that for the most part, the health of incarcerated women is worse than that of incarcerated men and than that of women in the general population.1

A GROWING POPULATION IGNORED

Historically, women have been underrepresented at all levels of the criminal justice system. This under representation of women has resulted in a criminal justice system created by males for males in which the diverse needs of women are forgotten and neglected.2 Prior to the 1980s, when the female prison population was relatively low, this was not an issue that received a significant amount of attention. However, over the past 20 years, the number of women held in state and federal prisons has increased more than 6-fold, outpacing the growth rate of the male prison population. Statistics show that African American and Hispanic women constitute the fastest-growing prison population. Two thirds of women confined in local jails and state and federal prisons are Black, Hispanic, or members of other non-White ethnic groups.3

Despite the exponential increase in the number of female inmates, little attention has been given to their unique health concerns. For example, the gynecological needs of female inmates are often dismissed as not important by prison officials. Medical concerns that relate to reproductive health and to the psychosocial matters that surround imprisonment of single female heads of households are often overlooked. Women in prison complain of a lack of regular gynecological and breast examinations and say that their medical concerns are often dismissed.

Many incarcerated women have lacked health care prior to their imprisonment. In addition, a large proportion of this population are survivors of physical and sexual abuse, putting them at greater-than-average risk for high-risk pregnancies and life-threatening illnesses such as HIV/AIDS, hepatitis C, and human papillomavirus infection, which may increase risk for cervical cancer. Moreover, despite being imprisoned and presumably safe from harm, women in many prisons throughout the United States are victims of sexual abuse by prison staff. At times, such abuse occurs during routine medical examinations.

The increase in women’s imprisonment is largely a product of minor property and drug-related crimes. During the 1980s, the percentage of women charged with drug offenses skyrocketed when crack cocaine was introduced across the United States. This inexpensive drug created addicts in low-income areas, increased demand for drugs in urban areas, and was associated with violence. Many crack cocaine addicts, especially low-income women of color, funded their addiction by engaging in prostitution, theft, and drug distribution. Like men’s prisons, women’s prisons are fast becoming warehouses for those who have committed drug-related offenses. Unfortunately, drug rehabilitation programs are virtually nonexistent in these institutions. Consequently, inmates who are released without receiving drug rehabilitation find themselves falling back into addiction because they are unable to resist the environmental pressures that led them to become addicted in the first place.

WOMEN AND MEN ARE NOT THE SAME

Mandatory sentencing laws are applied equally to women and men, although women’s characteristics and their responsibilities and roles in crime differ from those of male criminals.4 Women generally play small parts in drug rings, but they often receive longer prison sentences than men because their limited knowledge of the drug operations leaves them without the means to negotiate deals or because they are afraid to testify against the violent male leaders of the rings.5

Women are also more likely than men to be solely responsible for their children. Two thirds of incarcerated women have children younger than 18 years; approximately 15% have infants younger than 6 weeks.6^,7 Between 5% and 10% of incarcerated women enter correctional facilities while pregnant.8^,9 Approximately 1.3 million children in the United States have mothers who are incarcerated.6 Hispanic and African American women are likely to have more children than their White counterparts, which makes them more likely to resort to criminal activities to make ends meet. Thus racial/ethnic socioeconomic disparities are partially responsible for the overrepresentation of minority women in prison.

Surveillance data clearly show that rates of psychiatric disorders are higher among incarcerated women than among women in the general population.10^–12 If it were not for inmates’ rights advocates (e.g., Prison Activist Resource Center, The Western Prison Project, the American Civil Liberties Union, and the Legislative Action Coalition on Prison Health), correctional administrators would feel little pressure to advance the mental health of female inmates. Most correctional health care reform has occurred because of litigation that resulted in court mandates for correctional facilities to make improvements.

Further disparities between male and female inmates exist in most correctional systems. Because of their small numbers, women prisoners are more likely to be incarcerated in a maximum security facility, where women of different security levels are either commingled or separated by internal housing classifications. Men, in contrast, are generally assigned to prisons on the basis of a variety of factors, including their criminal offense, prior criminal history, and psychological profile. Also, because of the greater number of male institutions, men stand a much better chance of being housed near their place of residence, making it easier for family, friends, and attorneys to visit. Until recently, most states maintained only one prison facility for women, often located far from a major urban center; consequently, most female prisoners were geographically isolated from their children and from legal and community resources.

In comparison to prisons for men, rules within women’s prisons tend to be greater in number and pettier in nature. Women prisoners are commonly cited for disciplinary offenses that are typically ignored within male institutions, and while they are less violent than their male counterparts, they appear to receive a greater number of disciplinary citations for less serious infractions.

THE IMPACT OF LITIGATION

Challenges to disparate educational and vocational programs have met with more mixed success. In many state and federal correction institutions housing male inmates, educational and vocational training is typically the norm, whereas such programs in women’s institutions are rare. There is a continuing need to expand training for female inmates to provide them with marketable skills that will help them return to community life.

When suits have been settled out of court, states have generally agreed to augment and improve prison programs for women. But when a department of corrections declines to settle a suit and the case goes to trial, incarcerated women have fared less well. In 1997, in Klinger v Department of Corrections (107 F3d 609 [8th Cir 1997]), the Eighth Circuit Court of Appeals reversed a district court decision directing the state of Nebraska to provide women inmates with programs and services “substantially equivalent” to those offered to men. In that case, the circuit court determined that inferior programs for women could be justified because women prisoners in that state were not “similarly situated” to incarcerated men.

Almost all female inmates will eventually return to the community. Health matters that go untreated during incarceration, whether substance addiction or infection with a disease that may be transmitted to individuals in the general population, will still exist once the inmate has been released. For this reason, many public health professionals argue that risk reduction policies implemented by correctional policy-makers to advance the health and well-being of incarcerated populations will ultimately benefit the community at large.13

THE INVISIBLE WOMAN

Women, no matter their ethnic or cultural background, often feel invisible. The concerns that arise in women’s lives are often downplayed by all segments of society, including health care professionals. According to Taylor, African American women suffer a disproportionate risk of ill health just because they are Black,14 and the penal system is yet another health hazard for these women.

For women especially, being subjected to harm and violence may begin or hasten a descent into the abyss of criminal justice networks, family disruption, certain types of infectious diseases, and poor health—a cycle that is not taken into account by the judiciary when women enter the system. Women bear the brunt of the violence of poverty in this country. We must wonder why the criminal justice system is blind to this dynamic and to the horrific price that society pays when we simply incarcerate and do not rehabilitate the mind and the body.