Abstract
Objective:
Despite increasing representation of older women in U.S. jail and prison facilities, their menopause experiences and access to related care remain uncharacterized. Our objective is to explore the menopause experiences of people incarcerated in jail and prison facilities.
Methods:
We conducted a pilot study of four semi-structured in-depth interviews with people in the community who experienced menopause symptoms while incarcerated in either a prison or jail facility.
Results:
Preliminary findings suggest critical gaps in access to menopause-related resources and medical care. Participants described that lifestyle and medical interventions for menopause in prison were inaccessible, and that untreated symptoms contributed to significant distress. Participants reported feeling as though medical staff did not believe their concerns and were dismissive of their complaints. In some cases, menopause symptoms and symptom management exacerbated the ways in which institutional barriers reproduce criminalization within the carceral system.
Conclusions:
Individuals going through the menopause transition while experiencing incarceration have significant unmet needs and poor access to relieving lifestyle changes or medical interventions. Policy and practice changes should address menopause related needs of individuals experiencing incarceration.
Keywords: Menopause, Incarceration, Aging, Women’s Health
Introduction
The number of women over the age of 45 in US jails and prisons is increasing,1 but little is known about the unique healthcare needs of older women experiencing incarceration and the extent to which these needs are being met in jails and prisons. One in three older women in prison report menopause is an important health concern.2 The menopause transition is associated with a range of physical and psychological symptoms that last over 10 years, on average, and can significantly impact health and well-being.3 Conditions of incarceration may compound these adverse effects; most jails and prisons do not allow common lifestyle interventions to alleviate menopausal symptoms (e.g. layered clothing, cool drinks, frequent showers). Clinical menopause management may be constrained by concurrent management of other prevalent conditions among women experiencing incarceration.4 Understanding menopause experiences among people who are incarcerated is a critical step in identifying gaps in access to and quality of care for the underserved and growing population of older women in prisons and jails.
This brief report describes preliminary findings from interviews with people who experienced the menopause transition while incarcerated in a state prison or in a county jail in North Carolina. Analysis of their narratives reveals areas for future research and intervention.
Methods
To determine feasibility, appropriateness, and acceptability of conducting interviews with people in prison about their menopause experiences, we conducted a pilot study of in-depth, semi-structured interviews with people in the community who experienced menopause symptoms while incarcerated in a prison or jail facility. Each participant was interviewed one time between September and October 2020. Participants were recruited from two community programs in North Carolina. Program administrators provided study information to program participants in their 40s, 50s and 60s. Six individuals expressed interest in participation, and four met the eligibility criteria of having experienced menopause symptoms while incarcerated in a prison or jail facility. This study was approved by the University of North Carolina at Chapel Hill Institutional Review Board (IRB# 19–3421) and all participants provided written informed consent. As audio recording is not allowed in prison facilities, pilot interviews were also not recorded. Reports generated immediately after interviews from extensive field notes were analyzed using thematic narrative analysis techniques. Participant responses as recorded in interview notes are presented below in italics. Each participant was assigned a pseudonym for this report. Preliminary themes are described below.
Results
Four women participated in interviews, including Black and White women in their 50s and 60s who experienced menopause symptoms while incarcerated in a state prison or county jails.
Physical and psychological changes
Descriptions of experiences with menopause emphasized both physical and psychological dimensions. All participants described physical symptoms including hot flashes, fatigue, night sweats, trouble sleeping, chills, migraines, urinary incontinence, vaginal dryness, irregular bleeding, breast soreness, body aches, and changes in hair, appetite, and weight. Psychological symptoms were described as changes — becoming irritable or sad with minimal provocation — that impacted well-being. Diane described,
My mental health deteriorated, I had no control. I have bipolar with anxiety and depression, and PTSD. When menopause hit, I had to increase the amount of medication necessary.
She reflected on shared experiences among menopausal women in prison,
A lot of women had mental issues that got out of control, and a lot of us got suicidal.
Janet attributed aggressive engagement with others to the ephemeral but intense emotions:
I would almost be in a fight, cussing people out, and then just crying right behind it after the big argument, just go into an emotional fit and just cry.
These experiences prompted loneliness. Janet shared,
I didn’t have anybody in my corner.
Participants described feeling shame and discomfort due to odors from urinary incontinence and night sweats, blood stains on clothes and sheets, and outbursts of interpersonal aggression. Distress was heightened by inadequate provision of resources or privacy to manage symptoms.
Barriers to non-pharmacological symptom management
Participants described difficulty with accessing supplies to manage menopause symptoms. In jail, Candace experienced heavy bleeding, but was not provided enough sanitary pads, replacement underwear or clothing, or clean bedding. When she first asked for supplies, she was told to wait. She asked,
How you supposed to wait when you flowing heavy, how I supposed to tell my cycle to wait?
Then remembered,
It felt nasty, you messed up your sheets and your panties, you got on that big orange suit...The suit was bloody, I was bloody, the sheets was bloody. I washed it out, but then I had to put it on the bed cause I didn’t want to sleep on that plastic mattress.
Profuse sweating and hot flashes were worsened by being forced to live with few ceiling fans and no air conditioning. Mya shared,
If I could have just cooled down a little bit, perhaps it wouldn’t have been so bad.
She also confirmed that exercise and fresh air were restricted,
They didn’t take us outside…it was terrible.
While Diane was able to exercise through her job as a prison recreation clerk, she described her shifts during Southern summers as exacerbating hot flashes.
Barriers to medical care for menopause symptoms
There were numerous barriers to accessing medical care for menopause symptoms. Participants felt medical staff
Did the bare minimum [and suspected they were] trying to get high.
Diane described poor access to medical care in prison
It was a fight to get meds. It’s a struggle to get medical or mental health help
She reflected that women’s healthcare in particular suffered:
They treated us as if we had the same medical issues that men have.
She felt dismissed by prison clinicians,
The doctors acted like you didn’t know what you were talking about. They acted like you didn’t know your own body… If you’re not dying, they won’t do anything…with regards to menopause, they just say ‘you’ll get through it.’
Janet sought care once, but never returned, even though her symptoms worsened. She shared,
I asked if there was something they could give me. I don’t know why I didn’t get anything prescribed
Instead, she was told it would
Just get worse [and there was] nothing they could do.
Another barrier was cost, Janet stated,
They would dock from my pay, they would take $3 from the $7 I got each week if I went to medical. So I never went back to medical for it.
Lack of knowledge about medical management options also prevented her from seeking treatment; Janet was concerned about being prescribed narcotics and was afraid of hormonal medication’s potential side effects. Two women did not seek medical care, as they felt menopause was something to
Deal with [and let] run its course
They worried medication would prolong or delay — but not lessen — symptoms.
Lack of social and informational support
All women described a lack of social and informational support to manage distressing menopause related symptoms. Two participants who did not know their symptoms were related to menopause until they were incarcerated ascribed symptoms to detoxification or withdrawal from substances. Janet shared,
I didn’t know what I was experiencing, didn’t know if it was getting drugs out of my system.
During her first hot flash, Candace thought she had the flu. Participants described that clinicians, staff, and peers could serve as important sources of support and information about menopause. Mya recommended,
There should be knowledge about that. To know what it is and to know how to help. They should know that we’re going through these changes and how to care for ourselves at that time.
When clinicians offered informational and social support, respondents noted how it made a positive difference. Candace said of one jail nurse,
She realized I didn’t know I was going through menopause….she showed sympathy and compassion…She taught me a lot of the simple stuff and it really helped.
However, participants also identified the critical need for support beyond facility staff. For example, Candace felt she could not be candid with the nurse,
Even though I had been in and out of that jail, and I knew her, I didn’t feel like I could talk to her about the drugs I had mixed up together. How I thought I was having a reaction.
Peers going through the menopause transition were also named as important sources of psychosocial support. For Diane, it was useful when
you weren’t the only one going through it.
She suggested a support group, as
knowing you’re not alone sometimes works.
Criminalization of menopause within carceral systems
Participants described concerns about sanctions related to experiences with menopause, including those that resulted in negative conduct records and criminal charges. Diane described punishment for emotional outbursts she associated with menopause. Her attempts to manage hot flashes were also sanctioned;
If you rolled up your sleeves, it was a writeup. If you rolled up your pant leg, it was a write up. You have to sleep in bra and panties. Sometimes you can get away with no bra, but if you get strip searched and you don’t have panties on, it’s a write up.
A write-up cost Diane money or time in administrative segregation. She also was punished when — as a side effect of hot flash medication — she was unable to produce urine and could not complete mandatory drug testing. In one case, menopause was a factor in perpetuating a cycle of incarceration. Candace went straight from one county’s jail to court in another county. She was not provided sufficient sanitary pads in jail and made a makeshift pad from toilet paper, after a guard failed to follow through on a promise to bring hygiene products. This stopgap measure was insufficient; in order to appear in court without blood on her garments, she stopped to change clothes. She described,
I needed to take a shower before I went to court, so we stopped at my aunt’s house, my sister ran down the street to the Walmart and got me panties and jeans cause they didn’t wash my clothes in [county jail]. That’s why I was late.
This delay caused her to miss the court’s start time. Cited with a failure to appear, she was arrested and spent an additional ten days in jail.
Discussion
While a small dataset, interviews provide important perspectives on unmet needs of people experiencing menopause and incarceration. Women who experience incarceration face a disproportionate burden of conditions associated with more severe menopause symptoms (e.g. substance use disorders, HIV) and determinants associated with HPA-axis alterations that may exacerbate menopausal symptoms (e.g. low socioeconomic status, mental health disorders, histories of abuse and neglect).5–12 Despite severe menopause symptoms, preliminary findings indicate this population faces critical barriers to accessing resources for symptom management. In jails and prisons, allocation of hygiene products is restricted. Recent legislation guarantees adequate menstrual hygiene products for federal prisoners, but meaningful restrictions remain on access and people incarcerated in state prisons, and jails are left out of this progress.13 Lack of access to menstrual hygiene products to manage menopause related symptoms inhumanely strips people of autonomy and dignity. Average summer temperatures in North Carolina hover around 90 degrees,14 but most jail and prison buildings have no air conditioning and few ceiling fans. While likely uncomfortable for all people experiencing incarceration, enduring a hot flash in such conditions may constitute cruel and unusual punishment. The American College of Obstetricians and Gynecologists and the National Commission on Correctional Health Care recommend that people experiencing incarceration receive treatment for menopausal symptoms, but more data is urgently needed around the extent to which standards for menopause care in the community (e.g. care recommendations from the North American Menopause Society and the International Menopause Society) are being implemented jail and prison facilities.15–17
Preliminary data underscore the need for improved healthcare and health programming for older women experiencing incarceration. Programs offering aerobic exercise and stretching may mitigate symptoms, and educational programs may empower women to seek healthcare or resources for symptom management.18,19 Many prisons offer support programs to improve management of certain conditions (e.g. substance use disorder or pregnancy). To our knowledge, there are no support programs specific to menopause offered in carceral settings. Improving social support in jail and prison facilities may offer mortality benefits beyond improvements in quality of life; outside of carceral settings, lower perceived social support among menopausal individuals is associated with higher risk of death.20
Another important emergent theme from preliminary findings is that institutional barriers to menopause management can reproduce criminalization within the carceral system. Participants described a range of collateral consequences of menopause – they were punished for behavior that they attributed to symptoms, for actions taken to mitigate symptoms, or for side effects of medication taken to manage symptoms. While one of many compounded injustices faced by individuals caught in discriminatory cycles of incarceration, actionable solutions for menopause management in carceral settings exist, and present attainable opportunities for reducing harm perpetuated by mass incarceration.
Conclusion
Interviews with people who experienced the menopause transition while incarcerated in prison and jail facilities revealed disruptive and negative experiences of menopause symptoms and low access to medical and non-medical symptom management in these settings. While limited by sample size, findings will inform planned interviews with people currently experiencing menopause and incarceration. This work will center the experiences of this growing and underserved population to support development and implementation of policies and programs to address their unique needs.
Supplementary Material
Acknowledgements:
We are grateful to the individuals who shared their stories and experiences for this research.
These findings were presented at the American Public Health Association 2020 Annual Meeting
Funding: This work was funded by a Carolina Center for Public Service Community Engagement Fellowship
Footnotes
Disclosures: All authors report no financial disclosures or conflicts of interest
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