a cross-sectional study
Abstract
Background
Women make up 5% of the European prison population on average. Almost invisible in prison and health research, and suffering the stigma associated with female offending, incarcerated women are often forgotten, and their specific healthcare needs remain much ignored. Combining face-to-face survey interviews and medical chart data, we aim to assess the health status, healthcare needs, and access to preventive medicine of women incarcerated in Switzerland.
Results
Sixty incarcerated adult women participated in a cross-sectional study to assess their life and incarceration histories, physical and mental health problems, medication, and use of medical services. Eligibility criteria were (a) an incarceration of at least four weeks and (b) the ability to provide written informed consent. Exclusion criteria were psychiatric instability and insufficient language competence.
Women’s average age was 34.3 years old (SD = 9.8); 45.0% of them were born in Switzerland, 33.3% in Europe and 15.0% on the African continent. Overall, 61.7% of women self-reported physical or mental health problems and 13.3% indicated they were once diagnosed with a sexually transmitted infection. Further, 78.3% of women were active cigarette smokers; more than one in three women reported alcohol use problems and almost one in two women had used at least one illicit drug in the year before incarceration. Depression and perceived stress scores were above clinical cut-off points for more than half of interviewed women. When asked how they rated their health, 68.3% of women felt it had worsened since incarceration. All but four women had accessed prison medical services; however, our study does not indicate whether women’s use of healthcare was indeed adequate to their needs.
Conclusions
This study demonstrated incarcerated women’s poor health and health-risk behaviours. Structural changes and gender-responsive health promotion interventions have the potential to improve the health of incarcerated women and help them return to the community in better health.
Background
Prison health, for long a secondary issue for prison institutions, is now recognized as a public health issue (Ramaswamy & Freudenberg, [52]). With the social disadvantage and serious health problems of the prison population, access to quality health services in prison is of vital importance (Ismail, Lazaris, O’Moore, Plugge, & Stürup-Toft, [29]). Yet prison systems are required to meet the health needs of individuals in prison with limited resources and while facing important organizational and ethical challenges (Elger, [16]). Incarcerated women have more, and more specific health problems than men, which places additional constraints on prison health services (van den Bergh, Gatherer, Fraser, & Moller, [61]). In Switzerland, as elsewhere in Europe (Walmsley, [63]) one in 20 incarcerated persons is a woman. Outnumbered by men in criminal justice and correctional populations, the specificities of women’s trajectories are often ignored (Jaquier & Vuille, [31]), and their specific health and social needs remain much neglected (Braithwaite, Treadwell, & Arriola, [7]; Swavola, Riley, & Subramanian, [59]).
Research has highlighted the complex and chronic health problems faced by incarcerated women before, during, and after incarceration (Braithwaite, Arriola, & Newkirk, [8]; Jaquier, Neri, Augsburger, & Clair, [30]; WHO & UNODC, [65]). Chronic conditions (e.g., asthma, cancers, cardiovascular diseases) have been found more prevalent among incarcerated women than among incarcerated men (Dean, [14]; McQueen, [42]). Gender differences persist even when accounting for demographic and socioeconomic factors and substance use (Binswanger et al., [5]). Incarcerated women display a large array of mental health problems, from depression to posttraumatic stress, often the consequences of violence and abuse (van den Bergh, Plugge, & Yordi Aguirre, [60]). The uniqueness of women’s trauma histories plays a critical role in explaining gender differences in mental health in prison, but also in substance abuse (Grella, Lovinger, & Warda, [22]; Moloney, van den Bergh, & Moller, [44]). Indeed, women entering prison have strikingly high rates of substance use problems (Binswanger et al., [5]). Also smoking is highly prevalent in this population thus putting incarcerated women at higher risk of smoking-related diseases (Cropsey, Eldridge, & Ladner, [12]; Plugge, Douglas, & Fitzpatrick, [50]). Last, because of sexual risk behaviours, drug use, sexual abuse, and often marginalized and socially deprived backgrounds, incarcerated women are at increased risks for sexual and reproductive health diseases, including cancers and sexually transmitted infections (STIs) (De Groot & Maddow, [13]; Macalino, [39]).
Incarcerated women’s health problems are further compounded by their limited access to healthcare prior to incarceration (Conklin, Lincoln, & Tuthill, [11]). Women’s physical and mental health is often poor upon prison admission and susceptible to deteriorate over time due to both the prison physical environment and the subjective experience of incarceration (Harner & Riley, [24]). Extant research has underscored that incarcerated women have a low utilization of healthcare services in the community and that, while in prison, they seek medical services to a greater extent than men (Lindquist & Lindquist, [38]; Staton, Leukefeld, & Webster, [58]). For many women, detention creates access to adequate healthcare services, possibly for the first time (Anderson, [1]). Research has therefore also underscored the essential role of screening and preventive medicine interventions during incarceration (WHO & UNODC, [65]).
Women’s increased vulnerability in prison poses unique challenges to medical professionals, when the incarceration exacerbates women’s mental health problems and traumatic experiences. Imprisoned women often serve a short sentence, resulting in a high turnover rate and thus complicating planning for continuous care. All along medical services for incarcerated women remain limited and often not tailored to their specific needs (Lewis, [37]; van den Bergh, Gatherer, & Møller, [62]).
That being said, most of the research on incarcerated women’s health has been conducted in North America or the United Kingdom and very limited research is available elsewhere in Europe (MacDonald, [40]). Yet women’s criminal trajectories, biographical and individual characteristics vary across countries, as do prison systems and accessibility of healthcare services. As such, extant international findings do not necessarily apply from one country to another.
So far, little is known about the current health status of women incarcerated in Switzerland. A few studies have compared the mental and physical health of men and (a few) women on remand (Eytan et al., [18]; Moschetti et al., [45]; Wolff et al., [66]), others have focused solely on women under forensic psychiatric care (Krammer, Eisenbarth, Fallegger, Liebrenz, & Klecha, [33]; Krammer, Linder, Peper, Covington, & Klecha, [34]; Rossegger et al., [53]), and a single study has described the health status of elderly (50+ years old) women in prison (Handtke, Bretschneider, Elger, & Wangmo, [23]). Specifically examining the case files of incarcerated women under forensic-psychiatric care, three studies conducted in the German-speaking part of Switzerland identified multiple aversive and potentially traumatic events in women’s childhood and adulthood and a history of psychiatric treatment, although two of these three studies comprised ≤20 women (Krammer et al., [33]; Krammer et al., [34]; Rossegger et al., [53]). In the French-speaking part of Switzerland, three studies analysing medical records found more frequent mental health problems in women, while the comparisons of the rates of physical health and substance use problems between men and women yielded inconsistent results (Eytan et al., [18]; Moschetti et al., [45]; Wolff et al., [66]). Yet, no study that we know of has collected comprehensive health data on incarcerated Swiss women’s health problems and needs, and overall prison experience using face-to-face survey interviews. There is a dearth of research to inform prison health and public health initiatives.
In 2017, 6907 persons were incarcerated in Swiss prisons, of which 382 were women (5.6%) (Office fédéral de la statistique, [48]). Switzerland holds 92 penal institutions, with a capacity ranging from five to 398 individuals. Two prisons are specifically dedicated to women, the Hindelbank prison located in the German-speaking part of Switzerland and the La Tuilière prison – where the study took place – located in the French-speaking part of Switzerland. Most women are housed in one of these two prisons, although some might be incarcerated in small sections of men’s prisons, which leads to gender discriminations in many areas including healthcare (European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment, [17]; Penal Reform International & Association for the Prevention of Torture, [49]). Access to quality healthcare vary greatly across prisons: small prisons are not staffed with healthcare professionals every day, the number of trained professionals remains too low, overcrowding is a perpetual issue as is the increased use of short prison sentences, and interactions between judicial or correctional authorities and medical professionals have proven complicated (Chatterjee, Wolff, Baggio, & Gétaz, [9]).
Policy documents at different levels have underlined the complex health and social problems faced by incarcerated women in Switzerland and recognized the need to attend to their specific needs. Yet so far little has been done to move beyond drafting recommendations. As an attempt to address critical gaps in research and correctional clinical practice, we designed an observational study assessing women’s health status, healthcare needs, and access to preventive medicine. Exploring incarcerated women’s complex health problems and how these are further negatively impacted by their prison experience is the first step towards designing initiatives that meet the specific needs of this particularly vulnerable prison population, therefore contributing to reducing prison health and public health gender disparities.