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Access to health services is strained in our society in general, in prisons in particular, and in women's prisons most of all. Despite their rapidly growing numbers, women are still a small percentage of the prison population, and for that reason it has sometimes been considered less cost-effective to provide care for drug abuse and addiction, mental health issues, and counseling for trauma and posttraumatic stress disorder for incarcerated females (Teplin et al., 1997; Zaitzow, 2001).

One obvious significant and gender-specific health care issue is the need for adequate gynecological and obstetric services. At least 6% of female prisoners are pregnant when they are arrested. Since not all prisons and jails test all women, the prevalence of pregnancy is likely higher. For example, studies have found that about 18% of female inmates had given birth at some point during a past or present incarceration (Acoca, 1998; BJS, 1999b; National Institute of Justice, 2000; Women's and Children's Health Policy Center, 2000).

In the broadest terms, incarcerated women are less healthy than incarcerated men. Many women had poor health care prior to their arrest and incarceration. They are frequently survivors of sexual and physical abuse. Many are sex workers and are therefore exposed to both abuse and sexually transmitted diseases. Many have not received routine gynecological care and have not been treated for reproductive system disorders (Braithwaite, Treadwell, & Arriola, 2005). Many women have numerous health issues that are masked by drug dependency. Once sober, mental and physical health issues become apparent, ranging from dental problems to chronic infections.

Studies have demonstrated an extremely high prevalence of sexually transmitted diseases among female prison inmates. Not all those infected are diagnosed, because many facilities only test women who are symptomatic or who request testing. One study estimated that between 11 and 17% of women tested positive for chlamydia infection, while 9% tested positive for gonococcus infection. Juvenile facilities reported an even higher prevalence of infection. In Chicago, among female prisoners, the incidence of infection with chlamydia was 27% and that of gonococcus was 11%; the Birmingham rates were 22% and 17% (CDC, 1999). Annual data from the California Department of Corrections demonstrate an incidence among women of positive skin testing for tuberculosis of between 20 and 30%. In contrast, less than 0.5% of the general population demonstrate a positive skin test for tuberculosis. Another study from the California Department of Corrections showed that 54% of female prisoners tested positive for hepatitis C, as opposed to 39% of male prisoners (Acoca, 1998; CDC, 2005).

HIV/AIDS statistics are even more disturbing. Groups disproportionately affected by HIV/AIDS are the same socioeconomic and ethnic groups that are disproportionately represented in the prison population. Confirmed AIDS cases are three times higher in correction systems than in the United States as a whole.

The segment of society currently most affected by rising AIDS rates is that of adolescent and adult females (BJS, 2005a). There are a number of factors which account for the extremely high prevalence among females in the prison population. A large percentage of incarcerated women have a history of intravenous drug use, and studies have shown that many incarcerated women have shared needles. Incarcerated women have often traded sex for money or for drugs. Furthermore, the facts that women have poor health in general and high rates of sexually transmitted genital ulcer diseases in particular leave them vulnerable to infection with HIV.

Studies vary in their estimates of HIV prevalence but all demonstrate a higher percentage of HIV infection among female inmates than among males. One study reported that 2.2% of male offenders and 3.5% of female offenders are known to be HIV positive (Zaitzow, 2001; BJS 2005a). Many states do not test all entering inmates. Policies vary greatly from system to system but only 18 of 51 jurisdictions test all inmates on admission. The most common practice is to test inmates who exhibit symptoms or who ask to be tested. This is the case in 44 of 51 jurisdictions. Fifteen states test inmates who are in high-risk groups. Four jurisdictions and the Bureau of Prisons test inmates at release (Women and Children's Health Policy Center, 2000; Zaitzow, 2001). These cases are not distributed equally around the country. New York, Florida, and Texas have the largest number of identified HIV-positive inmates, accounting for 48% of confirmed AIDS cases. In New York, which does periodic blind testing, 14.6% of female inmates and 7.3% of male inmates were known to be HIV-positive (BJS, 2005a).

While many states provide state-of-the-art antiretroviral treatment to prisoners, the treatment of HIV requires specialist involvement. Most of the time, prison primary care doctors do not have the training and expertise to effectively treat infected women, and even if they do, they may lack the facilities and staff to do so, or a system to provide follow-up care (Farley et al., 2000; Zaitzow, 2001).

Theoretically, prison would seem to be an ideal situation for monitoring and treating disease, and for managing chronic conditions, from tuberculosis to HIV/AIDS. Instead, not only is there insufficient testing and limited treatment, there are often insufficient connections with health services outside the corrections system to provide further care. As a result, women may leave prison as sick as or sicker than when they arrived and in many cases they leave prison with insufficiently treated contagious diseases which can and will affect the community as a whole (Collica, 2002; Freudenberg, 2002, Braithwaite et al., 2005). Their health may deteriorate and they may wind up in emergency rooms, and in hospital beds, care which is significantly more expensive than treatment would have been within the prison system.

While these are issues for both men and women, they become gender specific, or perhaps more accurately gender critical, because without successful treatment and reentry programs women will have little choice but to return to a cycle of drug addiction, crime, and/or the sex trade.

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