Identifying and Ameliorating Lesbian, Gay, Bisexual, and Transgender Health Disparities in the Criminal Justice System

In their analytic essay, Baćak et al. (p. 994) shed light on health disparities experienced by justice-involved individuals from the lesbian, gay, bisexual, and transgender (LGBT) communities and point to possible social psychological, interpersonal, and structural determinants of these disparate health outcomes. Their review is necessarily limited by a shortage of studies on this important topic; however, the authors acknowledge this limitation, identify gaps in the literature, and suggest topics for additional study. Although the multilevel approach Baćak et al. adopted illuminates several important issues affecting justice-involved LGBT individuals, slight shifts in perspective highlight additional issues the authors do not address in detail.

CONSIDERING OTHER HEALTH OUTCOMES

The small but growing body of work on this topic (as well as the authors’ review of this literature) focuses on sexual and mental health outcomes, which, although important, have received far too much attention in LGBT health research. Foundational questions regarding these health outcomes have been asked and answered, and continuing to focus on the sexual and mental health of LGBT individuals risks fetishizing and pathologizing this community. Viewing these health disparities as part and parcel of minority stress, as Baćak et al. suggest, should draw our attention to other known consequences of chronic stress, such as dysregulated cardiovascular and immune functioning. Additional health disparities, such as higher rates of breast cancer, polycystic ovarian syndrome, and obesity among lesbians and an increased risk of developing an eating disorder and certain types of cancer among gay men, have been documented in the general population¹ and may be exacerbated by involvement in the criminal justice system. Expanding the scope of the health outcomes under consideration by criminal justice health researchers promises to advance our understanding of LGBT health, minority stress models, and the practices and processes that contribute to the health disparities experienced by justice-involved individuals.

We suggest that researchers who continue to study the sexual health of justice-involved LGBT individuals adopt a sex-positive perspective, which recognizes the value of sexual pleasure and intimacy. This perspective brings additional issues into focus—such as policies that prohibit and punish consensual sex among prisoners but allow law enforcement officers to engage in “consensual” sex acts with their detainees—that are particularly relevant to justice-involved LGBT individuals and could contribute to disparate sexual health outcomes experienced by this group.² Adopting this perspective also shifts the focus of the conversation from sexual harm reduction to sexual health promotion in the criminal justice system. For example, Meyer et al.³ argue that the criminal justice system is rife with opportunities for HIV primary and secondary prevention. Thinking about criminal justice health in terms of deficits and assets is necessary if we hope to capitalize on these opportunities for public health promotion.

DISAGGREGATING SEXUAL AND GENDER IDENTITY

Future research and writing on the health disparities that justice-involved LGBT individuals experience should follow the example of Baćak et al. by distinguishing between sexual and gender identity. All too often, research that is ostensibly about LGBT health ends up being about LGB health with the “T” simply tacked on for good measure. If we do not discuss the nuances of gender and sexual identity, we risk conflating the two and overlooking issues specific to justice-involved trans people. For example, correctional facilities routinely place trans prisoners in solitary confinement for their own “protection.” These measures make trans people particularly vulnerable to abuse by prison staff and to the serious psychological consequences of social isolation and deprivation,² which might contribute to disparate health outcomes.

Trans masculine individuals also face unique health challenges, although this group is rarely mentioned in the criminal justice health literature. For example, depending on whether and to what extent one has surgically transitioned, gynecological care, such as cervical cancer screening, and reproductive health services may be needed but may be incongruent with one’s gender identity. Given that trans masculine individuals are less likely to receive Papanicolaou tests and mammograms than are cisgender women in the general population,⁴ and that most jails and prisons lack appropriate gynecologic and obstetric care,⁵ it is unlikely that the specific needs of trans masculine people are being met. Additional research and reviews focused on the unique experiences of justice-involved trans people, including trans masculine individuals, are needed to determine the particular practices and processes that result in health disparities in these groups.

APPLYING THE SEQUENTIAL INTERCEPT MODEL

Our final set of recommendations are inspired by the sequential intercept approach to reducing justice involvement. Although originally developed to describe how individuals with mental illness become justice involved and how to prevent them from entering or becoming more deeply enmeshed in the criminal justice system, the model is applicable to other stigmatized and marginalized groups. The model identifies five points of interception or opportunities for intervention along the criminal justice system trajectory.⁶ Two of these points of interception—prearrest interactions with law enforcement and emergency services and the postarrest initial detention period—were beyond the stated scope of Baćak et al. but warrant our consideration and discussion.

First, numerous studies and legal cases document discrimination, abuse, and harassment of LGBT individuals by law enforcement officers, and qualitative research on the health care experiences of LGBT individuals and people living with HIV evidences stigmatizing and discriminatory treatment by emergency personnel.² Understanding the health disparities affecting justice-involved LGBT individuals will require further attention to this important point of first contact with the criminal justice system.

Second, with an estimated half-million Americans confined to jails each year while awaiting trial and an average of 68 days between arrest and adjudication, the pretrial detention period is another important point of interception. Even short jail stays have been linked to negative criminal justice and health outcomes. In fact, suicide, the leading cause of death in jails, is far more common among pretrial detainees, with the majority of jailhouse suicides occurring shortly after admission.⁷

Although Baćak et al. referenced jails and prisons in their essay, they did not have time to make fine line distinctions between the two and to explore the unique health threats posed during the pretrial detention period. Expanding the scope of future discussions to include both the point of first contact with the criminal justice system and the pretrial detention period will help paint a more complete picture of the health disparities created or exacerbated by mass incarceration.