Incarcerated Women: The Hidden Health Crisis in the US
Written by Elizabeth Gordon
The number of females in United States prisons has surged more than 800% since 1980, a rate twice as fast as that of male inmates. Yet, the criminal justice system upholds an imprisonment and healthcare model that, at best, ignores women’s health needs and at worst exacerbates their challenges.
Women who become involved with the justice system often come from disadvantaged backgrounds and face a multitude of challenges. They have lower education levels and are more likely than men to have experienced homelessness in the year before the arrest that led to their incarceration. Many have a history of childhood trauma, sexual violence, and domestic abuse. These factors, coupled with inadequate healthcare access, have contributed to a health crisis that disproportionately affects justice-involved women, particularly those who are Black and Latinx.
Studies have shown that incarcerated individuals have the health indicators of people ten years older than the general population. This accelerated aging can be attributed in part to poor living conditions, the impacts of structural racism, risky health behaviors, stress, and inadequate healthcare access before incarceration. However, for women, these factors combine with unmet parental, reproductive, and mental health needs during incarceration to compromise their health and wellness further.
While justice-involved people have some of the poorest health indicators of any population, women experience significantly higher rates of chronic illness, mental health concerns, and infectious diseases compared to their incarcerated male counterparts. Addressing the healthcare needs of incarcerated women is not just a matter of basic human rights, but also has significant implications for their families and communities. As nearly 95% of incarcerated women will eventually be released, it’s crucial to prioritize their health and well-being during and after incarceration to improve outcomes for all.
Healthcare in Jails vs. Prisons
Providing adequate healthcare services to incarcerated people is the responsibility of the government. The quality and access should be broadly equivalent to the services available in the community. However, the United States prison system is generally built on a male-specific model, leaving many correctional facilities significantly unprepared to meet the more, and unique, biological, psychological, and social health needs of women.
As of 2021, there are 976,000 women under the control of the US Corrections system. This includes 711,125 women who are on probation, 96,386 on parole, 85,100 in jails, and 83,349 in prison. Because of the predominantly non-violent nature of their crimes, the length of sentence, and other factors including the lack of facilities specifically for women, a disproportionate number of women are held in jails rather than in prisons. This distinction contributes to the poor quality of healthcare provided to women both before and after conviction.
The disparity in healthcare offered to women in prisons compared to jails boils down to differences in funding source and level. Jails are poorly positioned to provide proper health care and offer fewer services and programs overall. This lack of care has a detrimental effect on women who have a higher mortality rate than men in jails. Additionally, the number of deaths by suicide among incarcerated women has increased by almost 65% between the periods of 2000-2004 and 2015-2019.
Gaps in Care in Incarcerated Women’s Health
Despite women’s greater need, there are significant gaps and a lack of standardization in healthcare provided by the criminal justice system. The unaddressed health needs of justice-involved women span from preventive to palliative care.
For this article, we chose to focus on the mental, reproductive, and aging health needs of incarcerated women. Other areas that deserve equal attention however relate to parental health including access to contraceptives, abortion, perinatal care, breastfeeding, and family support as 80% of justice-involved women are mothers.
Mental and Behavioral Health
One of the most critical gaps in care in the U.S. criminal justice system is the lack of mental and behavioral health services. Women in prison are five times more likely to have mental and behavioral health concerns than the general female population. In prisons, 66% of females have a history of mental health diagnosis compared to 35% of males. Similarly, in jails, 68% of females had a history of mental health diagnosis compared to 41% of males. About 58% of women reported a substance use disorder the year before they went to prison, a significantly higher rate than among men.
Across the entire criminal justice system, one in three of all justice-involved women meet the criteria for post-traumatic stress disorder (PTSD). To put this in perspective, at some point in their life, 7 Veterans out of every 100, or 7%, will experience PTSD. Rates of PTSD are also almost three times as high in incarcerated women than in men.
Many justice-involved women also have a history of domestic abuse and sexual violence in addition to the trauma incurred from being in prison. Over half of the women in prison say they have suffered from domestic violence and have a history of childhood sexual abuse. Around 50 -75% have experienced a sexual assault in their lifetime. Not surprisingly then in prisons, 66% of women suffer from depression compared to 37% of men however, just 43% report having received professional mental health care since being in prison.
Women in prison account for 23% of all prison self-harm incidents despite representing just 5% of all prison populations and suicide among recently released female prisoners is 40x higher than the general population.
Mental health is a growing national crisis for women but the overwhelming majority of behavioral and mental health services remain out of reach for the population most at-risk of incarceration. FemHealth companies are addressing this crisis but great opportunities remain to support women dealing with a history of trauma, depression, and anxiety who are uninsured or on Medicaid.
Preventive Care
Reproductive care is a crucial aspect of women's overall health, but justice-involved women often lack access to these basic services before, during, and after incarceration. In many cases, incarceration presents one of the only opportunities for this underserved population to receive general medical, reproductive, or preventive health care.
Even though the National Commission on Correctional Healthcare (NCCHC) has issued guidelines on health standards for incarcerated women, few states take on all the initiatives needed to address the needs of this underserved population. Additionally, healthcare in carceral facilities tends to focus on acute health problems rather than preventing or effectively treating chronic or mental health conditions as evidenced by the fact that the Federal Bureau of Prisons does not require yearly preventive care visits.
While incarcerated, co-pays also present a large barrier to medical access for women and often cause them to delay or avoid medical treatment. People within the justice system lose access to both private insurance and Medicaid during their stay and often experience a gap in coverage upon release. Forty states require inmates to pay co-pays for medical care and incarcerated women pay the equivalent of $200 to $500 per visit when factoring in their wage-earning potential while serving time. Additionally, many federal prisons still do not have healthcare providers who are properly trained in obstetrics and gynecology leading to decreased rates of screenings and misinterpretation of test results.
Reproductive Health
The results of this lack of preventive care for women can cause permanent damage to their reproductive health — or even be deadly. Rates of breast and cervical cancer are higher among incarcerated women; likely related to under-screening both before incarceration and while in custody. Incarcerated women are 4-5 times more likely to have cervical cancer compared to women without criminal histories and some studies suggest that imprisoned women are also more vulnerable to mortality due to cervical cancer.
Sexually transmitted infections (STIs), which disproportionately impact the incarcerated female population, have both long-term and short-term impacts on women’s health. Left untreated, they can cause an increased risk of HIV infection, pelvic inflammatory disease (PID), cervical cancer, infertility, ectopic pregnancy, or adverse fetal and neonatal outcomes.
Menstruation
Menstrual products in jails and prisons around the country and limited, inadequate, and expensive. This forces many women to choose between hygienic care of their menstrual needs and necessary medical services given their limited financial resources.
While the First Step Act in 2018 mandated federal correction centers provide feminine hygiene products at no cost to incarcerated females, access to menstrual hygiene products is inconsistent and often inadequate. In fact, outside of federal facilities, just 13 state-run facilities offer free access to menstrual products. For those locations that offer free menstrual products, the products rarely meet industry standards for absorbency and as a result, many incarcerated women are forced to purchase their supplies from the commissary.
In states such as Missouri, incarcerated people with cycles made a base pay of $7.50 - $8.50 per month in 2021 while adequate alternatives of feminine hygiene products to supplement the non-absorbant sanitary napkins provided cost 70-80% of their monthly wage. The lack of sufficient products or resources to purchase them forces many women to create makeshift solutions that are often unsanitary. Some women use bunched-up toilet paper while others make their tampons out of mattress stuffing. These non-sterile “alternatives” increase the risks of infections and even Toxic Shock Syndrome.
While TSS affects about 1 person per 100,000 per year, the risk is disproportionately high in correctional facilities. In a survey of 90 women in a Missouri correctional facility, 28% of female inmates reported that they had some type of vaginal infection, including TSS, over the past six months.
Incarcerated women also experience gynecological conditions including irregular menstrual bleeding and menstrual dysfunction at higher rates than nonincarcerated women possibly associated with stress. To our knowledge, there are no studies documenting the prevalence of incarcerated women who suffer from endometriosis, PCOS, dysmenorrhea, or other painful menstrual-related conditions. More research is needed to understand the prevalence of these conditions as well as the available medical support.
Abortion
The Dobbs decision has made it more difficult for females across the U.S. to obtain an abortion but it’s created an almost insurmountable barrier for justice-involved women. For women who enter the justice system pregnant, being incarcerated — even if not yet convicted — can have a detrimental impact on their ability to get an abortion. Restrictive probation and parole conditions can create barriers to accessing reproductive health care, particularly in states that are banning or criminalizing abortion.
Similarly while in jail or prison, women’s access to abortion care varies greatly between states but also differs between prison to prison or jail to jail within each state based on individual policies and the whims of employees. Many corrections facilities make abortion care inaccessible by requiring incarcerated females to pay for their abortion including the procedure, transportation costs, and overtime for the guards.
Menopause
The transition to menopause is a largely neglected healthcare need for aging women in prison. Menopause causes a range of physical and psychological symptoms over a span of ten years that significantly impacts a woman’s health and well-being. Most jails and prisons do not allow common lifestyle interventions to alleviate menopausal symptoms and there is low access to medical interventions that might ease this transition.
Interviews with incarcerated women going through menopause show that symptoms of this phase of life can negatively impact their daily life and may even delay release. The women interviewed reported receiving sanctions for “emotional outbursts” potentially related to hormonal changes or medications. Attempts to deal with common symptoms such as hot flashes in facilities without air conditioning by, for instance, removing their bra at night to sleep, also resulted in write-ups.
These “small” infractions can add up. Analysis of lower-level infractions served in the justice system shows that women are punished at higher rates than men for lower-level infractions and face harsher penalties that can even delay their release.
The American College of Obstetricians and Gynecologists recommends that people experiencing incarceration receive treatment for menopausal systems, however, data tracking the extent to which these standards are being implemented in jails and prison facilities is lacking.
Currently, there are no support programs specific to menopause offered in carceral settings. This represents a huge area of opportunity as programs to support women going through menopause outside of correctional facilities receive more research, funding, and attention.
Opportunities
Data Collection and Analysis
Huge gaps exist in the data available on the female incarcerated population — especially related to reproductive health access and outcomes. Comparable data across the different facilities that women are housed in is necessary to identify gaps in care and policy changes that are needed.
Comprehensive care at the point of incarceration
The justice system should utilize the opportunity to provide comprehensive care for women who may not have access otherwise. Simultaneous initiatives that address disparities in health need to begin at the point of incarceration. This includes performing a detailed medical intake, providing necessary medical care including STI testing and treatment, breast and cervical cancer screening, prenatal care, emergency contraception, and routine gynecologic care with a skilled team of trauma-informed healthcare providers along with long-term mental and behavioral health services.
In an ideal world, healthcare in prison would not only serve as the safety net women need but would also build a pipeline to preventive care for women once they leave the system. To achieve this, we need to engage community providers and innovators in the FemHealth community.
Improved Community-based Care
The majority of women involved in the justice system need mental and behavioral interventions — not punishment. Programs that make it easier for both insured and uninsured women to access mental and behavioral health support are desperately needed. Additionally, organizations that can help provide a continuum of care for recently released women will help lower rates of recidivism, and improve the health of their families, and the entire community to which they are inextricably linked.
To learn more about incarcerated women’s health, check out the FemTech Focus podcast episode with Kimberly Haven, Executive Director of Reproductive Justice Inside.
Companies to watch
Mental Health
TARA Mind - A public benefit corporation on a mission to combat the mental health crisis in America by expanding safe and equitable access to psychedelic-assisted therapy.
Moodwellth - A digital mental wellness platform that provides content, connection, and holistic support for Black women by Black women.
Brave Health - A virtual-first behavioral health provider focused on serving Medicaid and Medicare populations.
Primary & Preventive Care
Wildflower - A women's health solutions company specializing in digital and value-based care.
Caresignal - A device-less remote patient monitoring system for value-based care organizations.
Hey Jane - A virtual clinic offering safe and private abortion care plus ongoing medical and emotional support.
About the Author
Elizabeth Gordon is a FemTech copywriter and content strategist, Director of content strategy and communications at FemHealth Insights and the FemTech Focus podcast.
