Janet is a 23-year-old new admission to a large urban correctional facility for women. She is infected with HIV, diagnosed three months ago during her previous incarceration, and has a 10-year history of heroin addiction. She has fresh track marks and will be sent to the Detox Unit. Her urine pregnancy test is positive, and her tuberculosis skin test (TST) is 10 mm. She was TST-negative during her last incarceration. She has three children — ages 15 months and 3 and 4 years. Her 15-month-old is in foster care and has just been diagnosed with HIV infection. Her two older children live with her sister and are not HIV-infected. She has maintained contact with all her children and is determined to stay clean and sober and participate in all the programs available to her during this incarceration. She is surprised about her pregnancy status and is undecided about what to do about it. She is asymptomatic and denies cough, fever, night sweats, fatigue, and weight loss.

Janet was sent for a stat chest radiograph, which was negative, and was referred to the infectious disease physician for management of her HIV infection and her positive TST. She was referred to an OB/GYN for her positive pregnancy test and to a substance abuse counselor for additional referrals into treatment programs.

Who are the women in prisons and jails?

Statistically, Janet is like many women who are under correctional supervision. They share a heavy burden of medical and mental health problems, often related to poverty, violence in their lives, and a lack of social support. Incarceration further isolates women from their community and from their children, often forcing children into foster care. Incarceration eliminates current income, reduces job prospects as a result of a history of incarceration, and can lead to homelessness.¹ Incarcerated women are a marginalized and medically underserved population with a high prevalence of physical and sexual abuse histories, high-risk sex and drug-using behaviors, and a multitude of needs that can benefit from prevention education, treatment programs, and compassionate nursing care.

The U.S. has the highest incarceration rate in the world.^2,3 At midyear 2004, the nation’s prisons and jails incarcerated 2,131,180 people.⁴ In addition, at the end of 2003, there were over 4.8 million people on probation or parole.⁵ A total of one million women — 1% of all adult American women — are under some form of correctional supervision. These women are mothers to an estimated 1.3 million minor children.¹

Women comprise 6.9% of the total U.S. incarcerated population.⁴ The majority of women’s offenses are related to drugs and/or alcohol, either directly, as in the possession or sale of illegal substances, driving while intoxicated, or commercial sex work in exchange for drugs and/or money for drugs; or committed while the offender was under the influence of drugs and/or alcohol.⁶ An increasing 17.2% of female inmates had violent offenses as their most serious charge in 2002.⁷ Three out of four violent women offenders committed simple assault, and 40% were perceived by their victims as being under the influence of alcohol and/or drugs at the time of the crime.⁶ Governmental policies, which in recent years were intended to reduce drug use, have resulted in increased imprisonment for longer durations and have disproportionately affected women, particularly those of color.

In the past decade, the number of female inmates has more than doubled, and the incarceration rate for women is increasing faster than the incarceration rate for men.⁴ Black females (with an incarceration rate of 359 per 100,000) were 2.5 times more likely than Hispanic females (143 per 100,000) and nearly 4.5 times more likely than white females (81 per 100,000) to be incarcerated in 2004. These differences among white, black, and Hispanic females were consistent across all age groups.⁴ In 1999, a study of female offenders reported that of an estimated 3.2 million women arrested, nearly two-thirds placed on probation were white, and nearly two-thirds of those detained or imprisoned were women of color.⁶

People of color are dramatically overrepresented among the incarcerated. Although blacks are imprisoned for drug offenses more frequently than whites, they do not use drugs more frequently. Whites are more likely to afford bail and superior legal representation and are thus less likely to serve time in jails or prisons.⁸

Culturally competent nursing and medical care are necessary to serve the many needs of the high proportion of black and Hispanic women in prison. Women of color will largely return to low-income communities of color to poverty and racism. The stigma of incarceration places these women at a higher risk of homelessness, unemployment, and social isolation than before their imprisonment. Appropriate programs and services for these women while they are incarcerated and after discharge can assist them in a successful reintegration into their communities.⁸

Other characteristics of incarcerated women

A study of newly admitted jail inmates in Massachusetts reported that 50% of female inmates had reported physical abuse in the past six months; 39% had made a previous suicide attempt; and 33% had worked in the sex trade, exchanging sex for food, drugs, or money.⁹

Nearly six in ten female state prison inmates have experienced physical or sexual abuse in the past; nearly 25% reported prior abuse by a family member.⁶

Female jail inmates have higher rates of dependence on alcohol and drugs compared to men — 52% compared to 44%.¹⁰ At year end 2002, 3% of female prison inmates were HIV positive compared to 1.9% of males.¹¹

Most women in the correctional system committed a drug-related nonviolent offense and have been in the correctional system before.^6,12 They are women of reproductive age with children, and with a history of sexual or physical abuse. The majority of incarcerated women are women of color.

Mothers in prison

Approximately seven in 10 women under correctional sanction are mothers of an estimated 1.3 million minor children; 64% of these women lived with their minor children before incarceration. Black children are nine times more likely than white children to have a parent in prison; Hispanic children are three times more likely than white children to have an inmate parent. Described another way, 7% of black children, 2.6% of Hispanic children, and 0.8% of white children had a parent in prison in 1999.^1,13

More than 60% of parents reported being held in a facility 100 miles from their last place of residence. As a result, women are often isolated from their families, who have difficulty traveling the long distances to visit due to inadequate financial resources and a lack of transportation.¹⁴ For some incarcerated women, this loss of contact may mean termination of their parental rights.² All states have laws permitting the termination of parental rights of parents who are incarcerated. Fifty-four percent of female state prisoners reported never having a personal visit with their children since admission. Nevertheless, 60% of mothers reported at least weekly contact with their children, 40% said they spoke to their children by telephone at least once a week, and 45% reported weekly mail contact with their children.¹³

Between 5% and 6% of women are pregnant at the time of their arrest. From 1997 to 1998, more than 2,200 pregnant women were imprisoned, and more than 1,300 babies were born in prison. In at least 40 states, babies are taken from their imprisoned mothers almost immediately after birth or at the time of the mother’s discharge from the hospital, preventing the parent-child bonding that is needed for the development of trust and security in children.² Children of inmates are six times more likely to be incarcerated at some time in their lives than those of noninmates, and young offenders are more likely to have parents who were incarcerated than nonoffenders.^15,16

Among state prisoners, parents were less likely than nonparents to be violent offenders and more likely to be serving a sentence for drug offenses. One in three mothers in state prisons committed her crime to get drugs or money for drugs. Because of the high percentage of drug-related crimes, the average sentence was a lengthy 94 months.¹³

Pregnant inmates with underlying medical and psychiatric disorders may need specialized prenatal and postnatal nursing care. Pregnant inmates can benefit from comprehensive prenatal education, including the health effects of drug, alcohol, and tobacco use, and parenting skills. Interventions to decrease their mental distress include self-help groups, stress management, and programs to enhance self-esteem.¹⁴

Increased contact between parents and their children contributes to an inmate’s successful reintegration into the community and reduces recidivism. While the need for family-oriented programs for inmates is recognized, there is great variability among state departments of correction as to the provision of these programs. Sixteen states and New York City provide families with visitation assistance. The Family Visiting Program provides free bus service from New York City and Buffalo to facilities throughout New York State. Eight states provide special in-facility housing for infants up to 18 months of age; one other state, Tennessee, has special housing for children between 6 months and 6 years of age.¹⁵ Alternative sentencing programs for mothers of small children are needed. Fostering and supporting parent-child relationships would be expected to reduce recidivism in the parent and reduce the risk of future incarceration of the children.^15,17

Communities of color have experienced a disproportionate burden of the adverse effects of governmental “zero-tolerance” drug policies.¹ The impact continues from one generation to the next as large numbers of children of color are raised with absent parents and resources are diverted toward prison expansion rather than community services.

Health problems of incarcerated women

Correctional facilities are reservoirs of physical and mental illness, especially infectious diseases and substance abuse-related disorders. Left untreated, these problems will continue to affect the communities to which inmates return.

General Health: In 1997, 34% of female state inmates reported a physical or mental impairment that limited their ability to work.¹⁸ In a health survey of 20 health concerns in a Massachusetts correctional facility, women reported higher rates of physical or mental impairment than men, 53% and 20% respectively, with the greatest differences in emotional/mental problems.⁹

It is estimated that nearly 80,000 inmates have diabetes, a 4.8% prevalence rate. The American Diabetic Association has recently set general guidelines for diabetic care in correctional institutions, which address intake screening and management of diabetes. Additionally, the guidelines recommend that correctional institutions identify particularly high-risk patients in need of more intensive evaluation and therapy, including pregnant inmates.¹⁹

Infectious Diseases: The correctional population carries a disproportionate share of the burden of infectious diseases. The rates of HIV, hepatitis C infection, and tuberculosis are much higher in inmates. A study of inmates in 1997 reported that 3% of the U.S. population spent time in a correctional facility that year, yet these inmates accounted for between 16% and 43% of these infectious diseases.²⁰

The prevalence of sexually transmitted infection (STI) is high among women entering correctional facilities. In the Massachusetts survey cited above, women were twice as likely as men to report a history of chlamydia, gonorrhea, syphilis, genital warts, or trichomoniasis.⁹ In a study of female inmates being released in Rhode Island, 73% did not use a condom during their last act of sexual intercourse, and 51% of women reported a history of an STD.²¹

Women who pass through the correctional system have a disproportionate burden of HIV, with infection rates higher in incarcerated women than men. In 2002, 1.9% of male inmates and 3% of female inmates were known to be HIV positive. Three jurisdictions, New York, Florida, and Texas, housed nearly one-half of all HIV-infected inmates in 2002.¹¹

Incarcerated people are at high risk of HIV and STDs because of injection-drug use and high-risk sexual behaviors. Women are at higher risk, too, because of gender-based needle-sharing and other drug-related behaviors. Women are more likely to share needles with their regular sexual partner and more likely to be the second or last to use the needle. Women are more likely than men to earn money for drugs for themselves and their sexual partner by commercial sex work.²² The correctional setting is critical for interventions for the prevention and treatment of infectious diseases. These interventions will benefit not only the inmates and their families, but also the communities to which they return.²⁰

Mental Illness: According to a 2003 Human Rights Watch report, prisons have become the nation’s primary mental health facilities as a result of the closure of mental health hospitals across the U.S. The imprisoned mentally ill are victimized by fellow inmates; punished by correctional staff for symptoms of their mental illness, such as self-injury, being noisy, or failure to follow orders; and are more likely to be housed in isolation.²³ 

Among state inmates in 2000, 27% of female inmates were receiving therapy or counseling, and 22% were on psychotropic medication.²⁴

In a study of newly admitted female inmates to a Massachusetts facility, 53% of women reported emotional/mental problems, compared to 20% of male inmates; and 39% of the female inmates reported a prior suicide attempt compared to 13% of male inmates.⁹ Nearly six in 10 female inmates reported prior physical and/or sexual abuse.⁶ In one study of HIV risk factors, it was found that those female inmates with the most severe mental illness also reported the most extreme sexual risk behaviors.²⁵ In another study of pregnant inmates, 100% of those who experienced childhood sexual abuse reported substance abuse.¹⁴ Women with early-abuse histories are more likely to have substance use, excessive risk-taking behaviors, and anger — factors that increase the risk of arrest and underscores the importance of offering mental health services in the correctional setting.

Adverse childhood experiences, including child abuse, may have long-term consequences on adult behaviors. Women who have been victimized previously experience low self-esteem and are often unable to negotiate safer sex or to protect themselves from further victimization. Psychiatric interventions that target posttraumatic stress disorder (PTSD) might result in reduced recidivism in incarcerated women.

Andrea Yates, a former oncology nurse who suffered from postpartum depression that worsened with subsequent pregnancies, killed her five small children in 2001 by drowning them in their bathtub. Andrea was sentenced to life in prison. Twenty European countries, Canada, and Australia recognize the biological changes of childbirth, and mothers with mental illness receive probation and treatment, with an emphasis on prevention and rehabilitation, unlike the U.S., which emphasizes punishment.²⁶

Substance Abuse: As noted above, the prevalence of a substance-abuse history is high in female offenders. In the Massachusetts study, more than two-thirds of the women had used drugs, with 80% of those substance abusers reporting use during the previous three months. Women reporting drug use were twice as likely as men to have shared needles and were more likely than men, 70% versus 50%, to have had confrontations with the law because of their drug use, to admit to having a drug problem, to have received previous drug treatment, and to want help with their drug problem.⁹

For the majority of incarcerated women for whom substance abuse is a problem, drug treatment is largely unavailable to them, either while they are incarcerated or when they are released. With limited access to mental-health treatment in the correctional setting, women are released to the streets with the same problems that led them to substance abuse and incarceration in the first place. Recidivism is high; 65% of women have prior convictions.⁶

In an evaluation of the availability of the treatment of alcohol and opiate withdrawal in U.S. jails, it is estimated that approximately 1% of incarcerated substance abusers receive detoxification for drug and/or alcohol withdrawal.²⁷ It is also estimated that over 550,000 individuals return to their communities each year, most of them with untreated drug abuse problems.²⁸ In an evaluation of drug treatment programs under the Federal Bureau of Prisons, it was reported that approximately two-thirds of women entering drug treatment completed the programs.²⁸

Facilities designed for men

Historically, correctional facilities have predominantly held men. The criminal justice system has not adapted its security procedures to address the special physical needs and circumstances of women. This can be particularly traumatic to the many female inmates who have previously been victimized by men. Women are confined to institutions designed and run by men. No prisons for women in the U.S. have all female staff. Men are present when women dress, shower, and toilet. Male guards continue to perform pat-down body searches.²⁹ A Human Rights Watch report from 1996 describes the sexual abuse of female inmates at the hands of male correctional staff. The report states that despite international rules to the contrary, male staff hold positions where they are in constant close proximity to women inmates in the dorms where they live.³⁰

Nursing in the correctional setting

Incarcerated women have many serious medical and mental health needs, often longstanding and a result, directly or indirectly, of victimization. Most of these women are poor and have struggled with addiction, illness, violence, and caring for their children. Women in prison are generally undereducated about health matters and basic body functions and can benefit greatly from high-quality nursing care and health education.

However, nurses may find it difficult to care for people whose behaviors they consider morally objectionable. Additionally, the correctional environment can foster uncaring behaviors because its core functions are custody and control. Correctional nurses are trained not to hold conversations or to develop relationships with inmates. While this is to protect nurses from manipulative prisoners, it also serves to undermine the caring behaviors that are the cornerstone of nursing practice. Nevertheless, the opportunity to care for women who lack access to the services that could assist them in addressing their many unmet needs can be very rewarding.⁸

In the Massachusetts survey, about 25% of male inmates and 50% of female inmates expressed interest in having medical staff help them with their health problems.⁹ In a study of women in a Canadian facility, 75% of those interviewed said they would accept a Pap test if it were offered to them while incarcerated.³¹ A study of HIV patients in Connecticut facilities reported that trust and a therapeutic relationship were correlated with acceptance of and adherence to antiretroviral therapy.³² Women in the correctional setting may be very accepting of the medical, nursing, and mental health care they receive from clinicians they trust.

The incarcerated woman is a challenging patient with a wide range of psychosocial and medical needs. The correctional nurse must be an adept health educator to assist the inmate patient in understanding her disease condition and the purpose of treatment to maintain adherence, often to very complex medication regimens. The correctional nurse, already in a unique work environment, has the opportunity to acquire expertise in many specialized areas, such as infectious diseases, high-risk pregnancies, polysubstance abuse, and psychiatric and trauma nursing.

The role of the discharge nurse or the correctional community liaison nurse will hopefully continue to grow in importance. The challenges that female inmates face in their return to their community can be eased by comprehensive discharge planning and linkages to social supports and treatment programs in the community.

Alternative sentencing programs for nonviolent drug offenders provide treatment access and support services as an alternative to incarceration for drug-related crimes. A new model of care proposes care by advanced practice nurses, including basic physical and mental health services. An important benefit of such programs is the maintenance of the integrity of the family unit. Other benefits, including cost, reduction of recidivism, and improved health of participants have yet to be determined.³³

Public health opportunity

The war on drugs has focused on a punitive rather than a public health approach, that is, punishing individuals rather than working toward improving their social condition. For women, this approach has resulted in the disruption of families; a negative impact on children; and a perpetual cycle of early trauma and victimization, substance abuse, and incarceration from generation to generation. Many studies have demonstrated that substance abuse treatment can be effective in reducing illegal drug use, criminal activity, victimization, and the exchange of sex for drugs or money and improving pregnancy outcomes. Incarceration offers the nurse an opportunity to provide needed treatment and referral services for women who otherwise are medically underserved. Linking these women with services in their community and advancing health education and promotion at the family and community level can reduce the risk of recidivism and directly benefit the families and communities to which these women return.