POLICY & PRACTICE
Imprisonment and women's health: concerns about gender sensitivity, human rights and public health
Emprisonnement et santé des femmes: préoccupations relatives à la spécificité des sexes, aux droits humains et à la santé publique
Privación de libertad y salud de la mujer: inquietudes sobre la sensibilidad de género, los derechos humanos y la sanidad pública
Brenda J van den BerghI,*; Alex GathererI; Andrew FraserII; Lars MollerI
IWorld Health Organization Regional Office for Europe, Scherfigsvej 8 DK-2100, Copenhagen Ø, Denmark
IIScottish Prison Service, Edinburgh, Scotland
ABSTRACT
The health of prisoners is among the poorest of any population group and the apparent inequalities pose both a challenge and an opportunity for country health systems.The high rates of imprisonment in many countries, the resulting overcrowding, characteristics of prison populations and the disproportionate prevalence of health problems in prison should make prison health a matter of public health importance.
Women prisoners constitute a minority within all prison systems and their special health needs are frequently neglected. The urgent need to review current services is clear from research, expert opinion and experience from countries worldwide. Current provision of health care to imprisoned women fails to meet their needs and is, in too many cases, far short of what is required by human rights and international recommendations. The evidence includes a lack of gender sensitivity in policies and practices in prisons, violations of women's human rights and failure to accept that imprisoned women have more and different health-care needs compared with male prisoners, often related to reproductive health issues, mental health problems, drug dependencies and histories of violence and abuse. Additional needs stem from their frequent status as a mother and usually the primary carer for her children.
National governments, policy-makers and prison management need to address gender insensitivity and social injustice in prisons. There are immediate steps which could be taken to deal with public health neglect, abuses of human rights and failures in gender sensitivity.
RÉSUMÉ
La santé des prisonniers est l'une des pires de tous les groupes de population, et les inégalités apparentes constituent à la fois un défi et une possibilité pour les systèmes de santé nationaux. Le taux élevé d'emprisonnement dans de nombreux pays, le surpeuplement carcéral qui en résulte, les caractéristiques de la population emprisonnée et la prévalence disproportionnée de problèmes de santé en prison doivent faire de la santé en prison une question de santé publique primordiale.
Les femmes prisonnières constituent une minorité au sein de tous les systèmes carcéraux, et leurs besoins sanitaires spéciaux sont souvent négligés. Le besoin urgent d'examiner les services actuels est clair, selon la recherche, l'opinion d'experts et l'expérience de pays du monde entier. L'offre actuelle de soins de santé aux femmes emprisonnées ne parvient pas à répondre à leurs besoins et est, dans de trop nombreux cas, loin de ce qui est requis par les droits de l'Homme et les recommandations internationales. Les preuves incluent une absence de spécificité des sexes dans les politiques et les pratiques carcérales, des violations des droits humains des femmes et l'incapacité à accepter que les femmes emprisonnées aient des besoins sanitaires plus nombreux et différents des prisonniers de sexe masculin, souvent liés à des questions de santé en matière de reproduction, des problèmes de santé mentale, des dépendances aux drogues et des antécédents de violence et d'abus. D'autres besoins proviennent de leur fréquent statut de mère et du fait que ce sont généralement elles qui s'occupent principalement des enfants.
Les gouvernements nationaux, les décideurs politiques et la direction des prisons doivent faire face à l'absence de spécificité des sexes et à l'injustice sociale dans les prisons. Des mesures immédiates pourraient être prises pour faire face à la négligence de la santé publique, aux abus des droits de l'Homme et aux échecs de la spécificité des sexes.
RESUMEN
La salud de los presos se encuentra entre las peores de cualquier grupo de población y las desigualdades suponen tanto un reto como una oportunidad para los sistemas sanitarios de cada país. Las altas tasas de encarcelamiento en muchos países, el hacinamiento resultante, las características de las poblaciones privadas de libertad y la prevalencia desproporcionada de problemas sanitarios en las prisiones deben convertir la salud en las prisiones en un asunto de sanidad pública importante.
Las mujeres privadas de libertad constituyen una minoría en todos los sistemas de prisiones y, frecuentemente, se ignoran sus necesidades sanitarias especiales. La necesidad urgente de revisar los servicios actuales es clara. Esta necesidad se desprende de la investigación, de la opinión especializada y de la experiencia de países de todo el mundo. La provisión actual de asistencia sanitaria para las mujeres privadas de libertad no cubre sus necesidades y, en muchos casos, está muy por debajo de lo que requieren los derechos humanos y las recomendaciones internacionales. Las pruebas incluyen una falta de sensibilidad de género en las políticas y prácticas en las prisiones, violaciones de los derechos humanos de las mujeres y la no aceptación de que las mujeres privadas de libertad tienen más necesidades de asistencia sanitaria. Asimismo, tampoco se acepta que estas necesidades sean diferentes en comparación con las de los hombres privados de libertad. Gran parte de estas necesidades de las mujeres están relacionadas con temas de salud reproductiva, problemas de salud mental, drogodependencias e historiales de violencia y abuso. Las necesidades adicionales provienen de su frecuente condición de madre y, habitualmente, de cuidadora principal de sus hijos.
Es necesario que tanto los gobiernos nacionales como los responsables de la toma de decisiones y la administración de prisiones solucionen la falta de sensibilidad de género y la injusticia social en las prisiones. Existen pasos inmediatos que se podrían tomar para solucionar la desatención de la sanidad pública, los abusos de derechos humanos y la falta de sensibilidad de género.
Background
The public health importance of imprisonment is insufficiently recognized. This is despite the high numbers held in prisons in many parts of the world, the characteristics of prison populations and the disproportionate numbers of prisoners with serious health problems. Worldwide, around 10 million people are held in penal institutions.1 Almost half of the world prison population is imprisoned in three countries: China, the Russian Federation and the United States of America (USA), even though their total populations amount to only one quarter of the world population. If one looks at imprisonment rates, the number of prisoners per 100 000 population, considerable variation occurs between countries and regions. While nearly three fifths of countries have rates less than 150 prisoners per 100 000 and the median rate for the world as a whole is 145 per 100 000, the rate range is from 756 per 100 000 in the USA to 35 per 100 000 in the western part of Africa.1
In recent decades, there has been a marked rise in the numbers of prisoners in many countries. Prison populations have risen in 71% of the countries listed in the World Prison Population List.1 In the USA, the total number has risen from 450 000 in 1978 to more than 2 million by 2005 and in the United Kingdom of Great Britain and Northern Ireland, the prison population has doubled since 1990.2 The rise in prison populations has in many countries resulted in considerable overcrowding. The reasons for the increase in the number of prisoners in developed countries are only partly explained by variations in rates of crime. The main reasons are stricter sentencing policies; despite the introduction, at the same time, of new restorative justice approaches.
Prison health is an inevitable part of public health; there is an intensive interaction between prisons and society.3 Addressing health in prisons is essential in any public health initiative that aims to improve overall public health. The World Health Organization (WHO) Regional Office for Europe has specifically acknowledged this by its Health in Prisons Project since 1995,4 supporting Member States in improving public health by addressing health care in prisons and facilitating links between prison health and public health.
Prisoners do not represent a homogeneous segment of society. Many have lived at the margins of society, are poorly educated and come from socioeconomically disadvantaged groups. They often have unhealthy lifestyles and addictions such as alcoholism, smoking and drug use, which contribute to poor general health and put them at risk of disease. The prevalence of mental health problems is very high: some prisoners are seriously mentally ill and should be in a psychiatric facility, not prison. Moreover, communicable diseases such as HIV, hepatitis and tuberculosis are more prevalent in prisons than in the community.4 Many prisoners have had no contact, or very limited contact, with health services in the community before they were detained in prison. Access to, as well as quality of, health services in prison is of vital importance.
Most prisoners return to the community, sometimes after relatively short periods of time in prison. The high numbers imprisoned, their vulnerability and the prevalence of serious health conditions create a situation requiring attention. Moore & Elkavich state that public health is a discipline in a prime position to call attention to these issues, to design programmes to assist prisoners and their families and to influence the social environment so as to "change the political climate and social policy surrounding who's using and who's doing time".5
A close look at the needs of women in prison and related health aspects raised issues of gender inequity and insensitivity, of human rights neglect and showed a general lack of public health concern. A full report about the specific health problems and needs of women prisoners is available.6 In this paper we aim to draw attention to some of the main findings and to stress the necessity for action.
Profile of women prisoners
Worldwide, more than 500 000 women and girls are held in penitentiary institutions, either as pre-trial detainees or sentenced prisoners. They constitute a small proportion of the total prison population; in about 80% of prison systems worldwide, the proportion of women varies between 2% and 9% with a median of 4.3% in 2006.7 Women who enter prison usually come from marginalized and disadvantaged backgrounds and are often characterized by histories of violence, physical and sexual abuse. Disadvantaged ethnic minorities, foreign nationals and indigenous people constitute a larger proportion of the female prison population relative to their proportion within the general community, often due to the specific problems these vulnerable groups face in society.
Women prisoners are a small minority of the total prison population but there has been a noticeable rise in women's imprisonment in recent years. In some countries the rate of this increase has been higher than that of male prisoners.8 For instance in England and Wales, the number of imprisoned women has increased by more than 200% in the past 10 years, compared with a 50% increase in the number of imprisoned men during the same period.9
Since their foundation, prisons have been built and run to cope with the needs of the male majority. Until recent times, the small numbers of women prisoners were simply admitted to the same prisons and were expected to cope with the same routines and facilities as men. Lack of attention to the very different and often more complex needs of women has resulted in neglect of their human rights, disregard to international recommendations and many instances of social injustice. In a world where there are widespread and persistent inequities between women and men, societies continue to fail to meet the health needs of women at key moments of their lives.10 A review of gender equity in health states that the present position is "unequal, unfair, ineffective and inefficient".11
The small numbers of imprisoned women mean that there are fewer prisons for them, resulting in women often being imprisoned further away from their homes. This causes difficulties for the woman in maintaining her family ties and is especially a problem if she has dependent children. Many imprisoned women are mothers and usually primary or sole carers for their children.6 When a mother is imprisoned, her family will often break up, resulting in many children ending up in state care institutions or alternative care. Imprisonment far from home also complicates a woman's resettlement after release. The small number of women prisons also results in the collective accommodation of women convicted for a wide range of offences in a prison with a high level of security, needed only for very few women. In fact, by far the majority of offences for which women are imprisoned are non-violent, property or drug related12 for which they serve short sentences. A high security level is disproportionate to the risk they pose. Drug-related offences (usually for personal use) are one of the most common crimes committed by women.13
Health care needs
Women in prison generally have more, and more specific, health problems than male prisoners and tend to place a greater demand on the prison health service than men do. This is the case right from the start of their imprisonment, as so many women prisoners have had no contact with health services during the period before admission to prison.6 As a consequence, most women in prison have little idea of their own health status and may be less aware than most people of healthy lifestyles.
Women prisoners frequently suffer from mental health problems, among which post traumatic stress disorder, depression and self-harming are regularly reported.6 They suffer from mental health problems to a higher degree than for both male prisoners and the general population,8 with rates as high as 90%.13 Evidence shows that women prisoners are more likely to self-harm and commit suicide than male prisoners, while this is the opposite in the community.11 In England and Wales, women were found to be 14 times more likely than men to harm themselves and women are more likely than men to do so repeatedly.14 In the USA, female prisoners are three times more likely than male prisoners to report having experienced physical or sexual abuse before their imprisonment, often resulting in poor physical and mental health.6 A high proportion of women in prison suffer from an alcohol or drug dependency and problematic drug use rates are higher among women than men.12 In the European Union Member States and Norway, female prisoners are also more likely to inject drugs than male prisoners,15 thereby exposing themselves to the risk of contracting HIV and other bloodborne viruses. Women are at greater risk than men of entering prison with sexually transmitted infections such as chlamydia, gonorrhoea, syphilis and HIV/AIDS, often as a result of past high-risk sexual behaviours including prostitution, sex work and being a victim of sexual abuse.16 A Scottish survey in 2002 concluded that the severity of tooth decay was considerably worse in the prison population than in the community, especially for female prisoners.17 Moreover, women in prison have specific health issues; the most prominent are related to reproductive health such as menstruation, menopause, pregnancy and breastfeeding.6
Because of the short sentences that women often serve, there is a high turnover rate in women's prisons which means that there is an intensive interaction between the prison, the community and wider society.6 Added to the distance that often exists between women prisoners and their home, this exacerbates the problems which can arise if prison health is isolated from other health services and in which there is little or no link between services in prisons and the community. Continuity of care is important in ensuring postrelease services for any health problems identified during imprisonment. The rate of post-release overdose mortality among ex-prisoners, especially in the first weeks after release, is unacceptably high and more could be done to reduce it.18
The current situation
National governments are responsible for the provision of adequate health care to prisoners. Its quality and access should be broadly equivalent to the services provided in the community. However, in the majority of countries worldwide, responsibility for prison health lies with the ministry of justice or interior, instead of the ministry of health. This can contribute to isolation of prison health services from public health services, leading to difficulties in staff recruitment and quality assurance. Several countries have transferred the responsibility for prison health to the ministry of health and there are some others considering the move. A guidance document has been requested from the WHO Regional Office for Europe.
There are substantial differences between countries regarding healthcare provision to women prisoners. For instance, there is considerable variation in the availability of treatment and care for drug dependency including opioid substitution treatment and harm reduction measures such as needle and syringe exchange programmes. Services designed specifically for women, helping them to feel safe and supported and considering gender-specific issues, are seldom provided.12 There are differences in the ways that mental health issues are addressed. In some systems, mental health screening is not part of the normal procedure on entrance and women prisoners are not differentiated based on their mental health status. Mental health programmes are either non-existent or inadequate to address women's specific needs,19 which may result in severe damage to their mental health.20
The way in which prison services meet the reproductive health needs of women prisoners varies considerably. Unfortunately, in too many prison services, women's physiology, including menstruation and reproduction are still medicalized. Access to regular showers, free provision of hygiene products and sanitary napkins and possibility of regular exercise are not standard services. Furthermore, health-care for pregnant women in prison is often far from equivalent to that available in the community. Women in prison seldom have access to any maternal education during pregnancy to help prepare them for the birth. The nutrition offered in prisons often fails to meet pregnant women's needs. After giving birth, women in prison are frequently discouraged from breastfeeding as it is perceived as interfering with prison routines, even while it is widely recognized that breastfeeding is the best method of infant feeding.6 Furthermore, there is often a lack of support for women who have been victims of sexual or physical violence before their imprisonment.
Discussion
The evidence is systematic and consistent; women's specific needs are often unmet by prison services and by the prison environment. Moreover, there are considerable gaps between prison health and public health services. Politicians and the general public still seem to be unaware of these evident and unacceptable inequities.
Human rights and, in some cases, even basic standards of decency are unmet; prison systems not only fail to meet the gender and biological health needs of imprisoned women, but also the standards of humane care called for by international bodies, such as those highlighted by Amnesty International in its report on women in custody in the USA21 and the Institute on Women and Criminal Justice in its report on mothers, infants and imprisonment.22
To improve the situation will require awareness, thought and action at all levels of the policy-making chain: politicians, prison management, health advocates and prison staff. The following should be considered.
First, the principles that should define a health-care system for women in prison were defined in the WHO/ United Nations Office on Drugs and Crime (UNODC) Declaration.6 The first of these is that imprisonment of women should be considered only when all other alternatives are unavailable or unsuitable. This is even more important for pregnant women and women with young children. Its importance becomes very clear when the personal and social costs of imprisonment of women are considered, in the context of their pathways to crime and their roles in their social, family and community context.
To prevent imprisonment in the first place, community-based services need to be strengthened and more widely used, especially for substance use, sexual and reproductive health and mental health; these should also provide adequate care on release from prison. Evidence concerning community-based residential parenting programmes has led to the recommendation that, whenever possible, custodial parents and pregnant women within the criminal justice system should be housed in community-based settings. A recent report points out that community corrections programmes have been shown to protect public safety and reduce recidivism at a fraction of the human and economic costs of imprisonment.22
Second, important gaps remain in staff training. The determinants of criminal behaviour in women and the longlasting effects of histories of violence and abuse should be known and understood by those providing supervision and care for women prisoners. All staff working with women prisoners should have followed gender-sensitivity training to raise awareness of and improve response to these gender-related issues.6
Third, international standards are of vital importance and contain regulations specifically directed to prisoners or women, but they are necessarily general in their terms and do not always sufficiently guarantee the provision of services to meet women prisoners' specific needs. The Quaker Council for European Affairs has published a gender critique of the European Prison Rules, which lists amendments and additions to the European Prison Rules with the status, rights and welfare of imprisoned women in mind.23
Fourth, an important part of gender equity is acceptance of women's preferences with regard to health care. Health services for women in prison should be individualized as far as possible to meet the specific expressed needs of the women; this would include access to a female practitioner or the rigorous use of chaperones where this is not possible.6
Recent developments
There are encouraging signs that new approaches and plans are being produced in various parts of the world. There are changes planned in several of the relevant public services such as the police, probation services and community facilities, and reflected in initiatives of nongovernmental organizations. The trend is towards more emphasis on alternatives to custody, with more effort towards assessing and supporting women in their own place of residence in cases where they have committed a non-violent or minor offence. The legal and criminal justice systems are also changing, with new restorative justice approaches.24
During recent years, prison systems in many countries have developed initiatives such as mother-and-baby units for imprisoned mothers; in most countries in Europe it is possible for babies and small children to stay with their mother in prison, up to an average age of 3 years. Nonetheless, this option raises difficult problems and dilemmas.
Ideas relating to health promotion in prisons, especially in women's prisons, are developing. These include a more participatory approach,25 using community development methods, which could help considerably in making women prisoners more health literate and more confident to look after their own health and the health of their children.
There are two current initiatives well worth mentioning. First, the Thai government initiated a project called Enhancing Lives of Female Inmates (ELFI) in 2008, eventually leading to the development of a supplement to the United Nations Standard Minimum Rules for the Treatment of Prisoners.26 The supplementary rules ("Bangkok Rules") were approved in December 2010 by the Third Committee of the United Nations General Assembly at its 65th session and provide clear guidelines for countries worldwide (available from: http://www.un.org/News/Press/docs/2010/ga11041.doc.htm). The Rules aim to raise awareness and set important standards. They are a useful tool for human rights and prison organizations to advocate for better conditions as well as gender-sensitive care and diversion schemes for imprisoned women worldwide.
Second, the WHO Regional Office for Europe and UNODC are following up on their Declaration on Women's Health in Prison by developing practical checklists and guidance notes. The checklists will be aimed at three levels: (i) ministers and policy-makers; (ii) prison management; and (iii) prison health staff. The aim is to support Member States with practical means to assess their current situation regarding women prisoners' health and the health services provided. The checklists and guidance notes are expected to be published later this year.
Conclusion
The high cost of imprisonment of women, in financial, social and health terms, makes crime and punishment a challenging political problem. When the degree of social disadvantage and the amount of serious disease in prison populations is considered, imprisonment becomes an important public health challenge, especially as most prisoners will be released into the community. An appeal to human rights and internationally agreed recommendations should be enough to correct many of the present difficulties; when combined with strong public health reasons, the case for priority and action is overwhelming. The case for women is even stronger.
Considerable review, policy development and change are required. While there may have been increased awareness of the problems and perhaps of willingness to change, the overall current position remains unacceptable. Radical change in criminal justice systems would take considerable time, but there are immediate steps that could be taken to deal with the more gross examples of public health neglect, abuses of human rights and failures in gender sensitivity. 
Acknowledgements
This paper would not have been possible without the work of UNODC and the research work of the Quaker United Nations Offices in Brussels and Geneva. We also acknowledge the advice from various experts worldwide.
Competing interests: None declared.
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(Submitted: 17 September 2010 Revised version received: 1 June 2011 Accepted: 7 June 2011 Published online: 6 July 2011)
* Correspondence to Brenda J van den Bergh (e-mail: bvb@euro.who.int).