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Incarcerated women in life context
Women’s Studies International Forum, Vol. 26, No. 1, pp. 95 – 100, 2003 Copyright D 2002 Elsevier Science Ltd Printed in the USA. All rights reserved 0277-5395/02/$ – see front matter
doi 10.1016/S0277-5395(02)00358-8
INCARCERATED WOMEN IN LIFE CONTEXT Seijeoung Kim College of Nursing, University of Illinois at Chicago, 820 S. Morgan St. #2, Chicago, IL 60607, USA Hektoen Research Institute, Chicago, IL, USA
Synopsis — The proportion of female inmates in the United States has steadily increased over the last several decades. Incarceration exposes these women to various health risks. Poor ventilation and a closed environment facilitate transmission of communicable diseases, and the rapid turnover of the population compromises continuity of care. Difficult life circumstances—poor socioeconomic conditions and limited access to health care—make these women vulnerable even before incarceration. Significant numbers of female inmates are substance abusers and infected by HIV. In fact, a majority of female inmates are charged with drug-related activities; often, they engage in exchanging sex as a means to meet their financial needs or to pay drug money. Further, many of them have been physically and/or sexually abused. Issues of incarcerated women need to be viewed within a broader community context because substance abuse, HIV infection, violence issues, and disadvantaged socioeconomic conditions are all intertwined. Therefore, collaboration among correctional and community health care providers and other social services is critical to improve female inmates’ health and life conditions. D 2002 Elsevier Science Ltd. All rights reserved.
to improve their health status as well as life conditions. In developing the article, I have drawn from the literature and conversations with health care providers at a large urban county jail.
INTRODUCTION Incarcerated women in the United States are vulnerable in many ways. Not only is being confined in jail or prison a major disempowering experience, but women in correctional facilities are marginalized even before incarceration. A disproportionately high number of female inmates are poor and racial minorities. Many engage in high-risk health behaviors. Substantially higher rates of incarcerated women are substance abusers and HIV seropositive than in the general population. Many incarcerated women report that they have exchanged sex to meet their financial needs or to pay for drugs. Also, a significant number of them have experienced sexual or physical abuse. Female inmates present a variety of health issues due to their high-risk behaviors and difficult life circumstances. The women’s poor economic and social conditions also limit their access to health care. The purpose of this paper is to review issues concerning incarcerated women in the United States to better understand this population and to identify ways
WOMEN IN CORRECTIONAL FACILITIES Incarceration Women are an increasing proportion of inmates. There has been an annual average increase of 6.5% in the U.S. incarcerated population between 1986 and 1996. In 1996, local jails held over 518,000 adult inmates (Chaiken, 1999, p. 21). Overall, the number of jail inmates per 100,000 total U.S. population increased from 141 in 1988 to 222 in 1999 (Stephan, 2001, p. 1). Although there are fewer female than male inmates, the female group is growing faster with 58% growth between 1990 and 1996, compared to 40% for males (Chaiken, 1999, p. 3). Female inmates increased from 8.9% of the inmate population in 1988 to 11.2% in 1999 (Stephan, 2001, p. 3). How are female inmates different from males? They are charged with substantially different crimes. Females are more likely to be confined with simple
The author would like to thank Dorothy Murphy, RN, MS, and Judy Klaczak at the Cermak Health Services for their support and thought-provoking dialogues. 95
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charges. The Bureau of Justice Statistics reports that among those classified as violent offenders in 1998, 70% of women inmates committed simple assaults, compared with 55% of men. Simple criminal charges are primarily property crimes, such as simple theft, shoplifting, and trespassing, that reflect female inmates’ difficult life circumstances (Greenfeld & Snell, 1999, p. 2). Richie (1996) reports that a majority of incarcerated women in a New York prison lived below poverty level. They were vulnerable to crimes due to their insufficient options for living. On the other hand, female inmates are more likely to have killed somebody who was an intimate or a relative (Beck et al., 1995; Busch, 1999). A U.S. national report shows that among female inmates charged for murder between 1976 and 1997, 60% killed an intimate partner or a family member, compared with 20% of the male murder cases (Greenfeld & Snell, 1999, p. 4). Women’s intimate partner murders are usually accompanied by a prior history of a battering relationship. In many cases, there is prior evidence of physical and/or sexual attacks from an intimate male partner. Overall, relationships with intimates may exacerbate the stress in female inmates’ lives, rather than provide resources and supports (Busch, 1999; Richie, 1996; Walker, 1989; Websdale, 1999). What are the health issues for incarcerated populations? The current growth of the jail population is accountable to mandatory minimum sentences for drug crimes since 1989 (Gaiter & Doll, 1996; Perkins, Stephan, & Beck, 1995). An increasing number of female inmates have been charged for drug-related offenses (Beck et al., 1995; CDC, 1996; Harlow, 1998). Often, female inmates commit crimes for money to buy drugs. Between 1990 and 1996, 37% of convicted female jail inmates were drug-related offenders, compared with 27% among male inmates (Greenfeld & Snell, 1999, pp. 6 and 9). Richie (1996) describes the increased use of drugs in inner city women as a desperate expression of their suffering and hopelessness. Also, as observed in HIV cases, a battering relationship often precedes drug use. Battered women’s longing for a deeper connection with partners leads them to drug use. Often, these women report that by using drugs with their partner, they feel emotional intimacy. Nevertheless, drug use leads them to deeper physical, psychological, and social destruction (Busch, 1999). Paradoxically, many inmates receive better health care in jail than in the community where they live. In fact, health care services in jail offer an opportunity to provide basic health care to those who are otherwise
excluded from health care systems in our society. Unfortunately, however, in most cases, inmates are released without notification to health care providers, and health care providers in jails often lose contact with inmates after their release (Braithwaite, Braithwaite, & Poulson, 1999; Johnson, 1995). Thus, once released, it is not guaranteed that inmates will obtain needed health care. Jail inmates are subject to frequent transfers from one tier to another or to prisons. Also, more than 50% of the people arrested return to the community within few days without being convicted. In 1992, 9.9 million inmates were released after an average length of stay of 15 days (Greifinger, Heywood, & Glaser, 1993, p. 333). The difficulty in screening and lack of continuity of care increase risks of various infectious diseases, including HIV, sexually transmitted diseases (STDs), and tuberculosis (TB) among inmates (CDC, 1996, 1999; Maruschak, 1999).
Racial and Socioeconomic Disparity Strong associations between socioeconomic level and health status have been reported in previous studies (e.g., Busch, 1999; Nyamathi, Flaskerud, & Leake, 1997; Pivnick, Jacobson, Eric, Doll, & Drucker, 1994). Not only individual social and economic conditions but also community socioeconomic and environmental aspects affect inmate health. Social and psychological disparities are predictive of poor health (Adler & Ostrove, 2000). Poor living conditions and limited access also are major obstacles to obtaining optimal health care. Inmates’ poor living conditions and marginalized social status compromise their health. Female inmates live under more difficult life circumstances than male inmates. According to a national survey on the U.S. incarcerated populations in 1995, 36% of the inmates were unemployed before their incarceration. The percent unemployment among female inmates (53.3%) was even higher than that of the total incarcerated population (Harlow, 1998, P. 4). In 1996, more than 64% of inmates had income less than US$1,000/month (Harlow, 1998, p. 4), and 37% of male inmates and 28% of female inmates earned less than US$600/month (Greenfeld & Snell, 1999, p. 8). About 30% of female inmates received social aid, compared with less than 8% of male inmates (Greenfeld & Snell, 1999, p. 8). The U.S. Bureau of Census reports that half of the single mother households fall below the poverty level and over 73% of poor black families are headed by women (Bunting, 1996, p. 5). Incarcerated women are likely to have dependent children. Most are of childbearing age, with 67%
Women in Jail
under 35 years and 92% under 45 in 1991 (Snell, 1994, p. 2). Sixty-seven percent have at least one child compared to 56% of male inmates (Beck et al., 1995, p. 10). Forty-two percent of female inmates report that they had two or more children and 6% were pregnant (CDC, 1996, p. 6). Female inmates in correctional facilities are mothers of more than a quarter million children, and therefore, female inmates’ incarceration directly affects dependent children’s lives. However, a majority of female inmates bear the burden of childrearing without a spouse. In 1998, 33% of female jail inmates were divorced or separated, and 48% were never married (Greenfeld & Snell, 1999, p. 7). Racial inequality also contributes to the less privileged economic and social status of inmates. A disproportionately high number of U.S. jail inmates are black (Kurshan, 1998). In 1996, whites made up 42% of the total jail population, blacks, 41%, and Hispanics, 16% (Chaiken, 1997, p. 16). The racial disparity is even greater among women. Relative to the number of residents in the U.S. population, black women (375 per 100,000) were twice as likely as Hispanic women (142/100,000) and seven times more likely than white women (53/100,000) to be incarcerated in 1999 (Gaiter & Doll, 1996, p. 21). The rate of incarceration for intimate partner murders among blacks was much higher than that of whites. As noted earlier, females are more likely than males to be incarcerated for intimate partner murders.
Drug Use A majority of incarcerated populations report a history of drug use and/or are confined by drug offenses (Wilson, 2000). According to a U.S. national survey in 1996, 8% of blacks and 6% of whites in the general population were illicit drug users (Department of Health and Human Services, 1997, p. 3). However, more than 83% of the prison population had used drugs in the past, and more than 70% were regular drug users in 1997 (Mumola, 1999, p. 7). In a U.S. national survey on incarcerated populations, 82% of female inmates reported that they used drugs some time and 64% used drugs regularly in 1996 (Mumola, 1999, p. 7). In fact, this high rate of drug use among female inmates is reflected in the rapidly increasing (432% between 1986 and 1991) number of female drug offenders (Beck et al., 1995, p. 7). Intravenous (IV) drug use is also associated with other infectious diseases. In fact, the recent HIV epidemic is closely linked to IV drug use. High HIV seropositivity rates are found in IV drug users
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and their sexual partners (Slovoda, 1998). Also, IV drug use exacerbates TB transmission. In one study, IV drug users were 17.2 times more likely to have TB infection (Sanchez, Alvarez-Guisasola, Cayla, & Alvarez, 1995, p. 633). Similarly, Bellin, Fletcher, and Safyer (1993, p. 2230) report that among inmates who were in a methadone detoxification unit, 63% had TB infection.
HIV Infection The proportion of all AIDS cases among adult and adolescent females increased more than three times from 7% to 25% in the period from 1985 to 1999 (CDC, 2002, p. 1). Also, there were 5279 reported AIDS cases among inmates, representing 0.52% of the incarcerated population in the United States. This is almost seven times the total U.S. adult population rate of 0.07% in 1994 (Brien & Beck, 1996, p. 4; Mahon, 1996, p. 1211). Some studies show that the HIV/AIDS rate in incarcerated populations is even higher in females than in males (e.g., Gellert, Maxwell, Higgins, Pendergast, & Wilker, 1993; CDC, 1995). The Bureau of Justice Statistics reports that of those who were tested for HIV infection, 2.1% of men and 3.4% of female inmates were HIV positive in 1999 (Maruschak, 2001, p. 4). The prevalence of the HIV/AIDS in the incarcerated population is consistent with the devastating HIV/AIDS epidemic in the black community. Although blacks represent 12% of the total U.S. population, they made up nearly 41.2% of the total U.S. AIDS cases in 2000 (CDC, 2001, p. 33). Further, 63% of female AIDS cases were blacks. Their incidence, 58.1 per 100,000 population, is twice that of Hispanics and eight times that of whites (National Center for HIV, STD, and TB Prevention, 1999, p. 1). In the Chicago area, whites were 48% of the total AIDS population in 1988, whereas blacks were 37%. Yet, by 1997, blacks were accountable for 68% of the total AIDS cases and whites, 18% (O’Brien, 1999, p. 9 and Appendix). This ethnic disproportion is even worse for women. HIV infection among U.S. women has increased significantly over the last decade, especially in ethnic minorities. Nearly 65% of all women reported with AIDS were blacks or Hispanics, whereas black and Hispanic women represent less than 25% of the total U.S. female population (CuUvin et al., 1996, p. 316). Women’s low social and economic status factors are linked to the prevalence of HIV infection in women inmates. Poverty is a factor in women’s exposure to HIV, particularly for those who engage in commercial sex work (Hudelson, 1996; Nyamathi
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et al., 1997) and many more women who do not necessarily view themselves as prostitutes, nonetheless reporting exchanging sex as a means to meet financial needs. The low status of women in society undermines the practice of safe sex. Many women with HIV had been unaware of the HIV status of their male sexual partners (Cu-Uvin et al., 1996; Nyamathi, Lewis, Leake, Flaskerud, & Bennett, 1995). Also, the options for safe sex, such as condom use, often are not under women’s control. Violence is another important factor affecting the impact of HIV prevention efforts. A history of sexual and physical abuse intensifies the women’s risk for HIV or other STD infection (Harlow, 1998; Puisis, 1998). Notably, approximately 40% of female inmates in a U.S. national survey in 1994 reported being physically and/or sexually abused and more than 30% of female inmates had experienced sexual abuse (Snell, 1994, p. 5).
Violence Incarcerated women are at higher risk of various forms of violence than other groups of women. The demographic characteristics of female inmates resemble survivors of domestic violence. Moreover, female inmates experience physical, psychological, or sexual abuses while they are incarcerated (Amnesty International USA, 1999). Over 60% of the U.S. female inmates have experienced physical or sexual abuse in the past. More than 50% of the female inmates have been abused by intimate partners, compared with 3% for men inmates (Snell, 1994, p. 6). Neighborhoods with fewer resources and high levels of drug use and HIV infection are especially inundated by high rates of street and domestic violence (Coker, Smith, McKeown, & King, 2000). Also, a history of exchanging sex for drugs or money and experience of childhood sexual abuse are identified risk factors for domestic violence in women (Harlow, 1998). Considering the significantly high rates of drug use, experience with physical or sexual abuse, and risky sexual behaviors, female inmates’ vulnerability to be victims of domestic and street violence is not ignorable (Cohen et al., 2000). As Richie (1996) and Walker (1989) describe, female inmates lose control over their lives through domestic and street violence in addition to their disempowering life circumstances.
CONCLUSION Female inmates feel lack of control while incarcerated due to separation from society, mandated uni-
formity, and the loss of physical and decision making freedom (Lilly, Cullen, & Ball, 1995). Female inmates also are disempowered due to their difficult life circumstances (Hardesty, Hardwick, & Thompson, 1993). The majority of incarcerated women are members of ethnic, social, and economic minority groups. They face a combination of severe economic hardship and difficulty obtaining access to health care. Many are exposed to increased risks of substance abuse and HIV infection. They are often victims of physical and sexual abuse (Nyamathi, 1998; Puisis, 1998; Vezeau, Peterson, Nakao, & Ersek, 1998). HIV infection and violence are disempowering aspects of women’s lives (e.g., Cohen et al., 2000; Sowell, Seals, Moneyham, Guillory, & Mizuno, 1999; Zierler et al., 2000). Many minority women perceive a high degree of stigma on account of race and poverty (e.g., Leenerts & Magilvy, 2000; Stephenson, 2000). The criminal history also stigmatizes incarcerated women. Women’s powerless status is also portrayed in their crimes. The crimes of women tend to fall into the simple charges category, mainly property crimes that arise out of difficult life circumstances and poor economic status (Feinman, 1994; Fletcher, Rolison, & Moon, 1993). Multiple factors influence incarcerated women’s perceptions of themselves. The conditions in which the women live must be acknowledged because individual behaviors cannot be decontextualized (Hildebrandt, 1999; Nyamathi, 1998; Vezeau et al., 1998). Thus, issues of incarcerated women need to be examined within a social context. It is inevitable that health care services for incarcerated women need to be provided while using multiple resources in the community. Collaboration between health care agencies and social services in and out of correctional facilities is essential. Health care delivery systems cannot fully function without integrating various health and social programs (Rothman, 1993). After all, health care cannot be separated from social development (Hemingway, Nicholson, & Marmot, 1997; Miller & Hirschhorn, 1995).
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AIDS prevention in prisons is good public health policy. American Journal of Public Health, 86(9), 1201 – 1203. Gellert, G., Maxwell, R., Higgins, K., Pendergast, T., & Wilker, N. (1993). HIV infection in the women’s jail, Orange County, California, 1985 through 1991. American Journal of Public Health, 83(10), 1454 – 1456. Greenfeld, L., & Snell, T. (1999). Women offenders. Bureau of Justice Statistics (NCJ-175688). Washington, DC: U.S. Department of Justice. Greifinger, R., Heywood, N., & Glaser, J. (1993). Tuberculosis in prison: Balancing justice and public health. The Journal of Law, Medicine, and Ethics, 21(3 – 4), 332 – 341. Hardesty, C., Hardwick, P., & Thompson, R. (1993). Selfesteem and the woman prisoner. In B. Fletcher, L. Shaver, & D. Moon (Eds.), Women prisoners: A forgotten population ( pp. 27 – 44). Westport, CT: Praeger. Harlow, C. (1998). Profile of jail inmates, 1996 (NCJ164620). Washington, DC: U.S. Department of Justice. Hemingway, H., Nicholson, A., & Marmot, M. (1997). The impact of socioeconomic status on health functioning as assessed by the SF-36 questionnaire: The Whitehall II study. American Journal of Public Health, 87(9), 1484 – 1490. Hildebrandt, E. (1999). Focus groups and vulnerable populations: insight into client strengths and needs in complex community health care environments. Nursing and Health Care Perspectives, 20(5), 256 – 259. Hudelson, P. (1996). Gender differentials in tuberculosis: the role of socio-economic and cultural factors. Tubercle and Lung Disease, 77, 391 – 400. Johnson, C. (1995). Evaluation of two-step tuberculosis test in a Massachusetts correctional facility. American Journal of Infection Control, 23(3), 209 – 212. Kurshan, N. (1998). Women and imprisonment in the US: history and current reality. [On line] Available at: http://www.prisonactivist.org/women/women-andimprisonment.htm. Leenerts, M., & Magilvy, J. (2000). Investing in self-care: a midrange theory of self-care grounded in the lived experience of low-income HIV-positive white women. Advances in Nursing Science, 22(3), 58 – 75. Lilly, R., Cullen, F., & Ball, R. (1995). Criminological theory: context and consequences. Thousand Oaks: SAGE. Mahon, N. (1996). New York inmates’ HIV risk behaviors: the implications for prevention policy and programs. American Journal of Public Health, 86(9), 1211 – 1215. Maruschak, L. (1999). HIV in prisons, 1997 (NCJ-178284). Washington, DC: U.S. Department of Justice. Maruschak, L. (2001). HIV in prisons and jails, 1999 (NCJ-187456). Washington, DC: U.S. Department of Justice. Miller, P., & Hirschhorn, N. (1995). The effect of a national control of diarrhea disease program on mortality: the case of Egypt. Social Science and Medicine, 40 (10), S1 – S30. Mumola, C. (1999). Substance abuse and treatment, state and federal prisoners, 1997. (NCJ-172871). Washington, DC: U.S. Department of Justice. National Center for HIV, STD, and TB Prevention (1999). HIV/AIDS among African Americans. [On line] Available at: http://www.cdc.gov/nchstp/hiv aids/pubs/facts/ afam.htm. Nyamathi, A. (1998). Vulnerable populations: a continuing nursing focus. Nursing Research, 47(2), 65 – 66.
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Nyamathi, A., Flaskerud, J., & Leake, B. (1997). HIV-risk behaviors and mental health characteristics among homeless or drug-recovering women and their closer sources of social support. Nursing Research, 46 (3), 133 – 137. Nyamathi, A., Lewis, C., Leake, B., Flaskerud, J., & Bennett, C. (1995). Barriers to condom use and needle cleaning among impoverished minority female injection drug users and partners of injection drug users. Public Health Reports, 110(2), 166 – 172. O’Brien, M. (1999). The faces of AIDS: The HIV/AIDS: Strategic plan for the Chicago area, 1999 – 2001. Chicago: The HIV/AIDS Strategic Planning Group. Perkins, C., Stephan, J., & Beck, A. (1995). Jails and jail inmates, 1993 – 1994 (NCJ-151651). Washington, DC: U.S. Department of Justice. Pivnick, A., Jacobson, A., Eric, K., Doll, L., & Drucker, E. (1994). AIDS, HIV infection, and illicit drug use within inner-city families and social networks. American Journal of Public Health, 84(2), 271 – 274. Puisis, M. (1998). Clinical practice in correctional medicine. St. Louis, MI: Mosby. Richie, B. (1996). Compelled to crime: the gender entrapment of battered black women. New York: Routledge. Rothman, D. (1993). The single disease hospital: why tuberculosis justified a departure that AIDS does not. The Journal of Law, Medicine, and Ethics, 21(3 – 4), 296 – 302. Sanchez, V., Alvarez-Guisasola, F., Cayla, J., & Alvarez, J. (1995). Preventive factors of Mycobacterium TB infections and pulmonary TB in prisons. International Journal of Epidemiology, 24(3), 630 – 636. Slovoda, Z. (1998). What we have learned from research about the prevention of HIV transmission among drug abusers. Public Health Reports, 113(Suppl. 1), 194 – 204. Snell, T. (1994). Women in prison. Bureau of Justice Statis-
tics (NCJ-145321). Washington, DC: U.S. Department of Justice. Sowell, R., Seals, B., Moneyham, L., Guillory, J., & Mizuno, Y. (1999). Experiences of violence in HIV seropositive women in the south-eastern United States of America. Journal of Advanced Nursing, 30 (3), 606 – 615. Stephan, J. (2001). Census of jails, 1999. Bureau of Justice Statistics (NCJ 186633). Washington, DC: U.S. Department of Justice. Stephenson, J. (2000). Rural HIV/AIDS in the United States: studies suggest presence, no rampant spread. Journal of American Medical Association, 284(2), 167 – 168. Vezeau, T., Peterson, J., Nakao, C., & Ersek, M. (1998). Education of advanced practice nurses: serving vulnerable populations. Nursing and Health Care Perspectives, 19(3), 124 – 131. Walker, L. (1989). Terrifying love: why battered women kill and how society responds. New York: Harper and Row, Publishers. Websdale, N. (1999). Understanding domestic homicide. Boston: Northeastern University Press. Wilson, J. (2000). Drug use, testing, and treatment in jails. (NCJ-179999). Washington, DC: U.S. Department of Justice. Zierler, S., Cunningham, W., Andersen, R., Shapiro, M., Nakazono, T., Morton, S., Crystal, S., Stein, M., Turner, B., St Clair, P., & Bozzette, S. (2000). Violence victimization after HIV infection in a US probability sample of adult patients in primary care. American Journal of Public Health, 90(2), 208 – 215.
doi 10.1016/S0277-5395(02)00358-8
INCARCERATED WOMEN IN LIFE CONTEXT Seijeoung Kim College of Nursing, University of Illinois at Chicago, 820 S. Morgan St. #2, Chicago, IL 60607, USA Hektoen Research Institute, Chicago, IL, USA
Synopsis — The proportion of female inmates in the United States has steadily increased over the last several decades. Incarceration exposes these women to various health risks. Poor ventilation and a closed environment facilitate transmission of communicable diseases, and the rapid turnover of the population compromises continuity of care. Difficult life circumstances—poor socioeconomic conditions and limited access to health care—make these women vulnerable even before incarceration. Significant numbers of female inmates are substance abusers and infected by HIV. In fact, a majority of female inmates are charged with drug-related activities; often, they engage in exchanging sex as a means to meet their financial needs or to pay drug money. Further, many of them have been physically and/or sexually abused. Issues of incarcerated women need to be viewed within a broader community context because substance abuse, HIV infection, violence issues, and disadvantaged socioeconomic conditions are all intertwined. Therefore, collaboration among correctional and community health care providers and other social services is critical to improve female inmates’ health and life conditions. D 2002 Elsevier Science Ltd. All rights reserved.
to improve their health status as well as life conditions. In developing the article, I have drawn from the literature and conversations with health care providers at a large urban county jail.
INTRODUCTION Incarcerated women in the United States are vulnerable in many ways. Not only is being confined in jail or prison a major disempowering experience, but women in correctional facilities are marginalized even before incarceration. A disproportionately high number of female inmates are poor and racial minorities. Many engage in high-risk health behaviors. Substantially higher rates of incarcerated women are substance abusers and HIV seropositive than in the general population. Many incarcerated women report that they have exchanged sex to meet their financial needs or to pay for drugs. Also, a significant number of them have experienced sexual or physical abuse. Female inmates present a variety of health issues due to their high-risk behaviors and difficult life circumstances. The women’s poor economic and social conditions also limit their access to health care. The purpose of this paper is to review issues concerning incarcerated women in the United States to better understand this population and to identify ways
WOMEN IN CORRECTIONAL FACILITIES Incarceration Women are an increasing proportion of inmates. There has been an annual average increase of 6.5% in the U.S. incarcerated population between 1986 and 1996. In 1996, local jails held over 518,000 adult inmates (Chaiken, 1999, p. 21). Overall, the number of jail inmates per 100,000 total U.S. population increased from 141 in 1988 to 222 in 1999 (Stephan, 2001, p. 1). Although there are fewer female than male inmates, the female group is growing faster with 58% growth between 1990 and 1996, compared to 40% for males (Chaiken, 1999, p. 3). Female inmates increased from 8.9% of the inmate population in 1988 to 11.2% in 1999 (Stephan, 2001, p. 3). How are female inmates different from males? They are charged with substantially different crimes. Females are more likely to be confined with simple
The author would like to thank Dorothy Murphy, RN, MS, and Judy Klaczak at the Cermak Health Services for their support and thought-provoking dialogues. 95
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charges. The Bureau of Justice Statistics reports that among those classified as violent offenders in 1998, 70% of women inmates committed simple assaults, compared with 55% of men. Simple criminal charges are primarily property crimes, such as simple theft, shoplifting, and trespassing, that reflect female inmates’ difficult life circumstances (Greenfeld & Snell, 1999, p. 2). Richie (1996) reports that a majority of incarcerated women in a New York prison lived below poverty level. They were vulnerable to crimes due to their insufficient options for living. On the other hand, female inmates are more likely to have killed somebody who was an intimate or a relative (Beck et al., 1995; Busch, 1999). A U.S. national report shows that among female inmates charged for murder between 1976 and 1997, 60% killed an intimate partner or a family member, compared with 20% of the male murder cases (Greenfeld & Snell, 1999, p. 4). Women’s intimate partner murders are usually accompanied by a prior history of a battering relationship. In many cases, there is prior evidence of physical and/or sexual attacks from an intimate male partner. Overall, relationships with intimates may exacerbate the stress in female inmates’ lives, rather than provide resources and supports (Busch, 1999; Richie, 1996; Walker, 1989; Websdale, 1999). What are the health issues for incarcerated populations? The current growth of the jail population is accountable to mandatory minimum sentences for drug crimes since 1989 (Gaiter & Doll, 1996; Perkins, Stephan, & Beck, 1995). An increasing number of female inmates have been charged for drug-related offenses (Beck et al., 1995; CDC, 1996; Harlow, 1998). Often, female inmates commit crimes for money to buy drugs. Between 1990 and 1996, 37% of convicted female jail inmates were drug-related offenders, compared with 27% among male inmates (Greenfeld & Snell, 1999, pp. 6 and 9). Richie (1996) describes the increased use of drugs in inner city women as a desperate expression of their suffering and hopelessness. Also, as observed in HIV cases, a battering relationship often precedes drug use. Battered women’s longing for a deeper connection with partners leads them to drug use. Often, these women report that by using drugs with their partner, they feel emotional intimacy. Nevertheless, drug use leads them to deeper physical, psychological, and social destruction (Busch, 1999). Paradoxically, many inmates receive better health care in jail than in the community where they live. In fact, health care services in jail offer an opportunity to provide basic health care to those who are otherwise
excluded from health care systems in our society. Unfortunately, however, in most cases, inmates are released without notification to health care providers, and health care providers in jails often lose contact with inmates after their release (Braithwaite, Braithwaite, & Poulson, 1999; Johnson, 1995). Thus, once released, it is not guaranteed that inmates will obtain needed health care. Jail inmates are subject to frequent transfers from one tier to another or to prisons. Also, more than 50% of the people arrested return to the community within few days without being convicted. In 1992, 9.9 million inmates were released after an average length of stay of 15 days (Greifinger, Heywood, & Glaser, 1993, p. 333). The difficulty in screening and lack of continuity of care increase risks of various infectious diseases, including HIV, sexually transmitted diseases (STDs), and tuberculosis (TB) among inmates (CDC, 1996, 1999; Maruschak, 1999).
Racial and Socioeconomic Disparity Strong associations between socioeconomic level and health status have been reported in previous studies (e.g., Busch, 1999; Nyamathi, Flaskerud, & Leake, 1997; Pivnick, Jacobson, Eric, Doll, & Drucker, 1994). Not only individual social and economic conditions but also community socioeconomic and environmental aspects affect inmate health. Social and psychological disparities are predictive of poor health (Adler & Ostrove, 2000). Poor living conditions and limited access also are major obstacles to obtaining optimal health care. Inmates’ poor living conditions and marginalized social status compromise their health. Female inmates live under more difficult life circumstances than male inmates. According to a national survey on the U.S. incarcerated populations in 1995, 36% of the inmates were unemployed before their incarceration. The percent unemployment among female inmates (53.3%) was even higher than that of the total incarcerated population (Harlow, 1998, P. 4). In 1996, more than 64% of inmates had income less than US$1,000/month (Harlow, 1998, p. 4), and 37% of male inmates and 28% of female inmates earned less than US$600/month (Greenfeld & Snell, 1999, p. 8). About 30% of female inmates received social aid, compared with less than 8% of male inmates (Greenfeld & Snell, 1999, p. 8). The U.S. Bureau of Census reports that half of the single mother households fall below the poverty level and over 73% of poor black families are headed by women (Bunting, 1996, p. 5). Incarcerated women are likely to have dependent children. Most are of childbearing age, with 67%
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under 35 years and 92% under 45 in 1991 (Snell, 1994, p. 2). Sixty-seven percent have at least one child compared to 56% of male inmates (Beck et al., 1995, p. 10). Forty-two percent of female inmates report that they had two or more children and 6% were pregnant (CDC, 1996, p. 6). Female inmates in correctional facilities are mothers of more than a quarter million children, and therefore, female inmates’ incarceration directly affects dependent children’s lives. However, a majority of female inmates bear the burden of childrearing without a spouse. In 1998, 33% of female jail inmates were divorced or separated, and 48% were never married (Greenfeld & Snell, 1999, p. 7). Racial inequality also contributes to the less privileged economic and social status of inmates. A disproportionately high number of U.S. jail inmates are black (Kurshan, 1998). In 1996, whites made up 42% of the total jail population, blacks, 41%, and Hispanics, 16% (Chaiken, 1997, p. 16). The racial disparity is even greater among women. Relative to the number of residents in the U.S. population, black women (375 per 100,000) were twice as likely as Hispanic women (142/100,000) and seven times more likely than white women (53/100,000) to be incarcerated in 1999 (Gaiter & Doll, 1996, p. 21). The rate of incarceration for intimate partner murders among blacks was much higher than that of whites. As noted earlier, females are more likely than males to be incarcerated for intimate partner murders.
Drug Use A majority of incarcerated populations report a history of drug use and/or are confined by drug offenses (Wilson, 2000). According to a U.S. national survey in 1996, 8% of blacks and 6% of whites in the general population were illicit drug users (Department of Health and Human Services, 1997, p. 3). However, more than 83% of the prison population had used drugs in the past, and more than 70% were regular drug users in 1997 (Mumola, 1999, p. 7). In a U.S. national survey on incarcerated populations, 82% of female inmates reported that they used drugs some time and 64% used drugs regularly in 1996 (Mumola, 1999, p. 7). In fact, this high rate of drug use among female inmates is reflected in the rapidly increasing (432% between 1986 and 1991) number of female drug offenders (Beck et al., 1995, p. 7). Intravenous (IV) drug use is also associated with other infectious diseases. In fact, the recent HIV epidemic is closely linked to IV drug use. High HIV seropositivity rates are found in IV drug users
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and their sexual partners (Slovoda, 1998). Also, IV drug use exacerbates TB transmission. In one study, IV drug users were 17.2 times more likely to have TB infection (Sanchez, Alvarez-Guisasola, Cayla, & Alvarez, 1995, p. 633). Similarly, Bellin, Fletcher, and Safyer (1993, p. 2230) report that among inmates who were in a methadone detoxification unit, 63% had TB infection.
HIV Infection The proportion of all AIDS cases among adult and adolescent females increased more than three times from 7% to 25% in the period from 1985 to 1999 (CDC, 2002, p. 1). Also, there were 5279 reported AIDS cases among inmates, representing 0.52% of the incarcerated population in the United States. This is almost seven times the total U.S. adult population rate of 0.07% in 1994 (Brien & Beck, 1996, p. 4; Mahon, 1996, p. 1211). Some studies show that the HIV/AIDS rate in incarcerated populations is even higher in females than in males (e.g., Gellert, Maxwell, Higgins, Pendergast, & Wilker, 1993; CDC, 1995). The Bureau of Justice Statistics reports that of those who were tested for HIV infection, 2.1% of men and 3.4% of female inmates were HIV positive in 1999 (Maruschak, 2001, p. 4). The prevalence of the HIV/AIDS in the incarcerated population is consistent with the devastating HIV/AIDS epidemic in the black community. Although blacks represent 12% of the total U.S. population, they made up nearly 41.2% of the total U.S. AIDS cases in 2000 (CDC, 2001, p. 33). Further, 63% of female AIDS cases were blacks. Their incidence, 58.1 per 100,000 population, is twice that of Hispanics and eight times that of whites (National Center for HIV, STD, and TB Prevention, 1999, p. 1). In the Chicago area, whites were 48% of the total AIDS population in 1988, whereas blacks were 37%. Yet, by 1997, blacks were accountable for 68% of the total AIDS cases and whites, 18% (O’Brien, 1999, p. 9 and Appendix). This ethnic disproportion is even worse for women. HIV infection among U.S. women has increased significantly over the last decade, especially in ethnic minorities. Nearly 65% of all women reported with AIDS were blacks or Hispanics, whereas black and Hispanic women represent less than 25% of the total U.S. female population (CuUvin et al., 1996, p. 316). Women’s low social and economic status factors are linked to the prevalence of HIV infection in women inmates. Poverty is a factor in women’s exposure to HIV, particularly for those who engage in commercial sex work (Hudelson, 1996; Nyamathi
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et al., 1997) and many more women who do not necessarily view themselves as prostitutes, nonetheless reporting exchanging sex as a means to meet financial needs. The low status of women in society undermines the practice of safe sex. Many women with HIV had been unaware of the HIV status of their male sexual partners (Cu-Uvin et al., 1996; Nyamathi, Lewis, Leake, Flaskerud, & Bennett, 1995). Also, the options for safe sex, such as condom use, often are not under women’s control. Violence is another important factor affecting the impact of HIV prevention efforts. A history of sexual and physical abuse intensifies the women’s risk for HIV or other STD infection (Harlow, 1998; Puisis, 1998). Notably, approximately 40% of female inmates in a U.S. national survey in 1994 reported being physically and/or sexually abused and more than 30% of female inmates had experienced sexual abuse (Snell, 1994, p. 5).
Violence Incarcerated women are at higher risk of various forms of violence than other groups of women. The demographic characteristics of female inmates resemble survivors of domestic violence. Moreover, female inmates experience physical, psychological, or sexual abuses while they are incarcerated (Amnesty International USA, 1999). Over 60% of the U.S. female inmates have experienced physical or sexual abuse in the past. More than 50% of the female inmates have been abused by intimate partners, compared with 3% for men inmates (Snell, 1994, p. 6). Neighborhoods with fewer resources and high levels of drug use and HIV infection are especially inundated by high rates of street and domestic violence (Coker, Smith, McKeown, & King, 2000). Also, a history of exchanging sex for drugs or money and experience of childhood sexual abuse are identified risk factors for domestic violence in women (Harlow, 1998). Considering the significantly high rates of drug use, experience with physical or sexual abuse, and risky sexual behaviors, female inmates’ vulnerability to be victims of domestic and street violence is not ignorable (Cohen et al., 2000). As Richie (1996) and Walker (1989) describe, female inmates lose control over their lives through domestic and street violence in addition to their disempowering life circumstances.
CONCLUSION Female inmates feel lack of control while incarcerated due to separation from society, mandated uni-
formity, and the loss of physical and decision making freedom (Lilly, Cullen, & Ball, 1995). Female inmates also are disempowered due to their difficult life circumstances (Hardesty, Hardwick, & Thompson, 1993). The majority of incarcerated women are members of ethnic, social, and economic minority groups. They face a combination of severe economic hardship and difficulty obtaining access to health care. Many are exposed to increased risks of substance abuse and HIV infection. They are often victims of physical and sexual abuse (Nyamathi, 1998; Puisis, 1998; Vezeau, Peterson, Nakao, & Ersek, 1998). HIV infection and violence are disempowering aspects of women’s lives (e.g., Cohen et al., 2000; Sowell, Seals, Moneyham, Guillory, & Mizuno, 1999; Zierler et al., 2000). Many minority women perceive a high degree of stigma on account of race and poverty (e.g., Leenerts & Magilvy, 2000; Stephenson, 2000). The criminal history also stigmatizes incarcerated women. Women’s powerless status is also portrayed in their crimes. The crimes of women tend to fall into the simple charges category, mainly property crimes that arise out of difficult life circumstances and poor economic status (Feinman, 1994; Fletcher, Rolison, & Moon, 1993). Multiple factors influence incarcerated women’s perceptions of themselves. The conditions in which the women live must be acknowledged because individual behaviors cannot be decontextualized (Hildebrandt, 1999; Nyamathi, 1998; Vezeau et al., 1998). Thus, issues of incarcerated women need to be examined within a social context. It is inevitable that health care services for incarcerated women need to be provided while using multiple resources in the community. Collaboration between health care agencies and social services in and out of correctional facilities is essential. Health care delivery systems cannot fully function without integrating various health and social programs (Rothman, 1993). After all, health care cannot be separated from social development (Hemingway, Nicholson, & Marmot, 1997; Miller & Hirschhorn, 1995).
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