PLOS ONE
RESEARCH ARTICLE

The body in isolation: The physical health
impacts of incarceration in solitary
confinement
Justin D. Strong ID1☯*, Keramet Reiter1☯, Gabriela Gonzalez1‡, Rebecca Tublitz1‡,
Dallas Augustine1‡, Melissa Barragan1‡, Kelsie Chesnut ID1‡, Pasha Dashtgard2‡,
Natalie Pifer3‡, Thomas R. Blair4‡

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Citation: Strong JD, Reiter K, Gonzalez G, Tublitz
R, Augustine D, Barragan M, et al. (2020) The body
in isolation: The physical health impacts of
incarceration in solitary confinement. PLoS ONE 15
(10): e0238510. https://doi.org/10.1371/journal.
pone.0238510
Editor: Andrea Knittel, University of North Carolina
at Chapel Hill, UNITED STATES
Received: February 19, 2020
Accepted: August 18, 2020
Published: October 9, 2020
Peer Review History: PLOS recognizes the
benefits of transparency in the peer review
process; therefore, we enable the publication of
all of the content of peer review and author
responses alongside final, published articles. The
editorial history of this article is available here:
https://doi.org/10.1371/journal.pone.0238510
Copyright: © 2020 Strong et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: Data cannot be
shared publicly because the administrative data we
analyze in this paper is drawn from a confidential
data file, shared with the research team for the

1 Department of Criminology, Law and Society, University of California, Irvine, Irvine, California, United
States of America, 2 Department of Psychological Sciences, University of California, Irvine, Irvine, California,
United States of America, 3 Department of Criminology and Criminal Justice, The University of Rhode Island,
Kingston, Rhode Island, United States of America, 4 Department of Psychiatry, Southern California
Permanente Medical Group, Downey, Los Angeles, California, United States of America
☯ These authors contributed equally to this work.
‡ These authors also contributed equally to this work. GG and RT are joint assistant authors on this work.
* jdstrong@uci.edu

Abstract
We examine how solitary confinement correlates with self-reported adverse physical health
outcomes, and how such outcomes extend the understanding of the health disparities associated with incarceration. Using a mixed methods approach, we find that solitary confinement is
associated not just with mental, but also with physical health problems. Given the disproportionate use of solitary among incarcerated people of color, these symptoms are most likely to
affect those populations. Drawing from a random sample of prisoners (n = 106) in long-term
solitary confinement in the Washington State Department of Corrections in 2017, we conducted semi-structured, in-depth interviews; Brief Psychiatric Rating Scale (BPRS) assessments; and systematic reviews of medical and disciplinary files for these subjects. We also
conducted a paper survey of the entire long-term solitary confinement population (n = 225
respondents) and analyzed administrative data for the entire population of prisoners in the
state in 2017 (n = 17,943). Results reflect qualitative content and descriptive statistical analysis. BPRS scores reflect clinically significant somatic concerns in 15% of sample. Objective
specification of medical conditions is generally elusive, but that, itself, is a highly informative
finding. Using subjective reports, we specify and analyze a range of physical symptoms experienced in solitary confinement: (1) skin irritations and weight fluctuation associated with the
restrictive conditions of solitary confinement; (2) un-treated and mis-treated chronic conditions
associated with the restrictive policies of solitary confinement; (3) musculoskeletal pain exacerbated by both restrictive conditions and policies. Administrative data analyses reveal disproportionate rates of racial/ethnic minorities in solitary confinement. This analysis raises the
stakes for future studies to evaluate comparative prevalence of objective medical diagnoses
and potential causal mechanisms for the physical symptoms specified here, and for understanding differential use of solitary confinement and its medically harmful sequelae.

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limited purpose of evaluating patterns of solitary
confinement use in the Washington department of
corrections. If any researchers wish to obtain a
similar data file from the Washington department
of corrections, the authors of this paper would be
happy to consult with those researchers about the
request and the process for obtaining the data. In
theory, the administrative data file used in this
study could be accessed again by future
researchers. Researchers would need to contact
the Washington department of corrections. Here is
the process and relevant contacts: https://www.
Doc.Wa.Gov/information/data/research.
Htm#requests. We confirm the authors have no
special access privileges others would not have to
the data underlying our study, beyond patient
negotiations with the Washington department of
corrections about exactly what data would be
shared for what purposes
Funding: KR received a Langeloth Grant from the
Jacob and Valeria Langeloth Foundation. https://
www.langeloth.org/. The funders had no role in
study design, data collection and analysis, decision
to publish, or preparation of the manuscript.
Competing interests: The authors have declared
that no competing interests exist.

The body in isolation

Introduction
The health implications of solitary confinement have received increasing attention in recent
years [1, 2]. Although both the conditions and terms defining solitary confinement are contested, the practice generally involves being locked in a cell alone, for 22 or more hours per
day, with extremely limited access to human contact and communication [3, 4]. Until recently,
however, research on the health consequences of solitary confinement has focused almost
entirely on the negative impacts on mental health [4–8]. While initial studies focused on the
effects of sensory deprivation [9–11], recent work has examined the impacts of social deprivations [12, 13]. Such studies have found that placement in solitary confinement has been associated with symptoms of increased psychological distress, such as anxiety, depression, paranoia,
and aggression [14–16]. A 2018 study, for instance, found that prisoners who had spent time
in solitary confinement were three times as likely to exhibit symptoms of post-traumatic stress
disorder (PTSD) than those who had not [17]. Some researchers, however, have argued that
the psychological harms of solitary confinement are limited or unverified [18, 19]. The analyses on which such opinions rely have, in turn, been criticized for neglecting existing literature
and for other serious methodological concerns, including an inability to isolate exposure to
solitary confinement, lack of specificity about variability and comparability in actual conditions of confinement, and the inapplicability of psychological assessment scales in the prison
context [1, 20].
In a study examining the lived experiences of solitary confinement in Washington state, we,
too, focused on documenting the mental health impacts of the practice, through qualitative
interviews with a random sample of 106 prisoners in long-term solitary confinement, application of a Brief Psychiatric Rating Scale (BPRS) assessment at two points in time with those prisoners, review of medical health records, and analysis of administrative data. To our surprise,
however, we found that, after anxiety and depression, the third most common significant
health symptoms experienced by our subjects were “somatic concerns,” defined by the BPRS
as “concerns over present bodily health” [21]. This observation led us to examine our data systematically for evidence of the impacts of solitary confinement on physical health, and to consider the implications of such impacts for understanding the health disparities enacted by
solitary confinement, and by incarceration more broadly.
Existing research on the physical health impacts of incarceration demonstrates the need for
further study of both the medical effects of isolation and its racially disparate impacts, especially considering that there are roughly 80,000 people in isolation units nationwide, and this
population includes a disproportionate number of racial minorities relative to the overall
prison population [22]. Outside of prison, health disparities by race and ethnicity are well
attested by existing epidemiologic research [23]. Notably, Black and other racial/ethnic minorities consistently show lower life expectancies and worse mental health outcomes than whites
[24–27]. Health disparities persist, and are magnified, among the incarcerated population,
where people of color are disproportionately represented [28–30]. In particular, people in
prison are at higher risk than the general population for substance use disorders, psychiatric
disorders, victimization, and chronic infectious diseases such as HIV and hepatitis C [31–34].
Incarceration has also been shown to exacerbate chronic illnesses such as obesity [35], hypertension, and asthma [36, 37, 29], and formerly incarcerated people experience disparately
adverse health outcomes more generally [38]. The interaction between the disparate impacts
of race and incarceration on health mean that mass incarceration itself has been identified as a
social determinant of health for Black men in the United States [39, 40].
Solitary confinement amplifies the disproportionately adverse effects of mass incarceration
on people of color. Depending on the composition of the prison system, Blacks and/or Latinos

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are often over-represented in solitary confinement relative to their (over)representation in the
general prison population [40–44]. Any concentrated health disadvantages affecting people in
prison, and especially people of color, is potentially even more concentrated among those living in solitary confinement. Moreover, existing evidence suggests that conditions of solitary
confinement exacerbate health problems and pose a significant public health risk [45, 42].
Studies reporting the physical health impacts of solitary confinement have tended to focus
on issues like self-harm and suicide [46, 47, 8]. One recent study has examined the cardiovascular health burdens of solitary confinement [45]. A growing body of neuroscience literature
has examined the effects of solitary confinement on the brains of lab animals, documenting
that lab animals in isolated environments have “a decrease in the anatomical complexity of the
brain” compared to those in more enriched environments [48, 49] (p70). One recent study
found similar effects in Antarctic expeditioners: a shrinking hippocampus, hypothesized to be
a result of the isolated and monotonous environment [50]. Such neuroscience research has
been used in litigation to argue that there is likely a similar effect on humans imprisoned in
solitary confinement [51, 48, 49]. The associations between solitary confinement, self-harm,
and lab animals’ brain structure suggest comorbidity between mental health and physical
injury in solitary confinement [1, 48].
The physical effects of solitary confinement manifest well beyond release from isolation,
and from incarceration overall. One recent study has examined post-release mortality (from
all causes, including suicide, murder, and drug overdose) associated with previous time in solitary confinement: people who had spent time in solitary confinement in North Carolina
between 2000 and 2015 were 24% more likely to die in their first year after release than former
prisoners who had not spent time in solitary confinement [52]. Similarly, a 2020 study found
that Danish people who had spent time in solitary confinement had higher mortality within
five years of being released from prison compared to those who never spent time in solitary
confinement [53]. This mortality risk associated with solitary confinement exceeds the already
high mortality risk associated with incarceration and release from prison [52–54].
In sum, while many studies have examined the relationship between incarceration and
health, and some studies have examined the relationship between solitary confinement and
mental health, the existing literature lacks analysis of disparate physical health outcomes across
levels and severity of confinement [2], especially within isolation, and for incarcerated people
of color. To our knowledge, this article is the first of its kind to consider associations between
solitary confinement and a range of physical health problems, and to incorporate explicit consideration of racial health disparities.

Methods and materials
To explore the physical health problems experienced in isolation, we draw upon a research
study of people in long-term solitary confinement in the Washington State Department of
Corrections (WADOC). The study consists of four dimensions of participant data: 1. surveys
of prisoners in solitary confinement; 2. in-depth interviews with a random sample of prisoners
in solitary confinement; 3. reviews of the medical (covering mental and physical health) files,
as well as the disciplinary records, for this subset of prisoners; and 4. administrative data for
the entire 2017 prison population provided by the WADOC. Data was collected in 2017 and
2018.

Setting
WADOC is a mid-sized state prison system, with the 12th lowest rate of incarceration of the 50
United States [20]. The state and its prison system have a reputation for being progressive,

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including engaging in reforms to minimize the use of solitary confinement statewide, and for
inviting independent academic researchers to evaluate conditions and programs [20, 55–57].
Five of the state’s 12 prison facilities have an Intensive Management Unit (IMU), an all-male
unit or building, housing people in solitary confinement (with highly restricted access to commissary, phones, radios, televisions, visitors, and roughly 10 hours per week out-of-cell) for
durations ranging from months to years. Our study focused on people within the IMUs on
“maximum custody status”: the highest security level assigned to state prisoners housed in the
IMU for an indeterminate period, usually following one or more rule violations, with return to
the general prison population contingent on meeting specific benchmarks.

Participant sampling
First, paper surveys were distributed in-person (and collected on the same day) to all 363 people on maximum custody status in the five state IMUs in the spring of 2017. Next, during the
summer of 2017, roughly one-third (29%) of all 363 people on maximum custody status in
IMUs were interviewed, selected from randomly ordered lists of the population of each IMU.
One year later (2018), all participants from our initial random sample, who were still incarcerated one year later, including those no longer housed in the IMU, were re-interviewed. We
also reviewed paper medical and disciplinary files for each consenting, year-one interview participant. Interviews, file reviews, and observations were conducted over two separate threeweek periods in the summers of 2017 and 2018, by a total of 13 research team members.
Finally, we received administrative data on all people within the state prison system as of July
1, 2017.

Research team training
All interviewers underwent an extensive training process, including more than 20 hours of
meetings to learn about conditions in Washington IMUs and develop the interview instrument. Interviewers completed an additional 20 hours of a standardized training protocol for
administering the BPRS in clinical settings: 16 hours of in-person symptom assessment training sessions with a leading expert in BPRS research—Dr. Joe Ventura—in year one, and four
hours of refresher training prior to the year-two interviews. Dr. Ventura conducted an interrater reliability analysis confirming trained raters met the minimum standard of an ICC = .80 or
greater for the BPRS. This extensive training sought to ensure that the 13 team members (9
women and 4 men; 9 white and 4 non-white), all faculty (4) or doctoral students (9) with
expertise in prisons and prior interview experience in secure confinement settings, identified
and addressed any pre-existing assumptions about the population being studied and minimized any possible bias as a result of inconsistent interpretation or application of questions
and assessments. Eight of the authors on this paper participated in interviews; two participated
only in data analysis.

Interviews
On site in the Washington State IMUs, after the random sample was drawn and willing participants identified, prison staff escorted participants, one at a time, to a confidential area (monitored visually but not aurally by WADOC staff). Prior to conducting interviews, interviewers
informed participants that participation was voluntary and would not involve incentives,
administrative or otherwise; that refusal would not affect them adversely; and that all information shared would be protected and anonymized, unless it pertained to “an imminent securityrelated threat.” (In the highly restrictive setting of the IMU, any incentive beyond providing
human contact and an attentive listener would both run the risk of being an undue influence,

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coercing participation, and be administratively prohibited.) Participants provided oral consent
to participate in the interview. Immediately following interviews, interviewers asked participants whether they consented to the research team reviewing their medical files and to participating in one-year follow-up interviews. All participants agreed orally to re-interviews, and all
but two (n = 104) consented in writing to medical file reviews. Following interviews, interviewers reviewed consenting participants’ paper medical files for histories of diagnoses, prescriptions, and substance abuse status; WADOC additionally provided electronic administrative
health and disciplinary files for all 104 consenting participants, as well as comparable, population-level data for all people incarcerated in the system in July 2017.
All identifiable data collected for this research, including interview audio recordings, transcripts, BPRS score sheets, medical file notes, and administrative data, was stored either in a
locked filing cabinet in a locked office of the university or in a secure server space, accessible
only through multi-factor identification to a subset of study team members participating in
data cleaning and linking. The University of California, Irvine, Office of Research Institutional
Review Board approved this study (HS 2016–2816), and the WADOC Research Department
reviewed this approval.

Data collection instruments
The initial paper survey of people confined in the WADOC IMU consisted of 36 numbered
questions (each containing a combination of yes/no, ordinal bubble options, and short answer
sub-questions leaving participants an opportunity to explain or elaborate on their answers)
about experiences in IMUs, conditions of confinement, health and well-being, and demographic background, drawing from existing studies on prisons and prisoner experiences [58–
62]. Survey in S1 Text. In all, there were 89 substantive items on the survey (excluding demographic questions) coded quantitatively as cardinal (e.g., number of days in IMU), ordinal (e.g.,
daily, weekly, monthly describing frequency of interactions), or categorical (e.g., yes/no) variables. In this paper, we report on the results of a sub-set of five quantitatively coded items relating to health from this larger survey. This survey functioned as a pilot instrument for the inperson interviews, allowing us to ensure questions were clear and relevant, yielding responses
comparable across subjects and institutional contexts, and providing our interviewers with a
baseline description of participants’ experiences prior to conducting qualitative interviews.
The qualitative interview instrument consisted of 96 numbered semi-structured questions
(each containing a combination of yes/no questions and probing, open-ended follow-up questions) seeking elaboration on responses from the survey questions and also drawing from
existing studies on prisons and prisoner experiences [60–63], including conditions of daily life
(prior to and during isolation), perceived state of physical and mental health, access to medical
treatment, and experiences with required programming in the IMU, among other topics.
Interview instrument in S2 Text. We first used the instrument at the smallest IMU in Washington, interviewing 15 prisoners, and we then revised both the wording and ordering of questions for maximum clarity and engagement in the remaining 91 interviews we conducted
across the four other IMUs in the state. In total, 40 of the substantive items on the interview
instrument (excluding 10 demographic questions and 18 embedded questions designed to
establish BPRS scores and/or assess orientation) were coded quantitatively as cardinal (e.g.,
How much does it cost to see a doctor or dentist?) or categorical (e.g., Have you noticed any
changes in your health since you have been in this IMU?) variables. Such questions always
included open-ended follow-up questions (e.g., Can you describe those changes?). Transcribed
responses to those open-ended follow-up questions, which related in any way to physical
health, constitute the central source of data analyzed in this paper.

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Interviews ranged in length from 45 minutes to three hours. Follow-up interviews lasted
between 45 minutes and two hours. The condensed year-two instrument contained approximately 70 questions, largely replicating the year-one questions, but excluding the background
demographic questions and questions about experiences over time in prison, and adjusting
some questions to address prisoners’ current (and often different) housing status.
As part of both initial and follow-up instruments, interviewers administered the BPRS psychological assessment both during (for the 14 self-report questions) and immediately following
(for the 10 observational items regarding a participant’s demeanor, engagement, and speech)
the interviews. For self-report questions (14 items), embedded in the interview guide, interviewers asked about the presence of symptoms in the two weeks prior, per BPRS standard [20].
Interviews were assigned a randomly generated identifier, audio recorded (with permission), professionally transcribed in Microsoft Word, translated (in one case, from Spanish into
English) by research team members, systematically stripped of identifying information, and
then systematically checked against the original audio by the original interviewer(s). Interviews
were linked, by random identifier to BPRS score sheets (which were scanned and entered into
Microsoft Excel for descriptive statistical analysis), scanned medical file review notes, and
WADOC administrative data.

Data analysis & reporting
BPRS and other administrative data were imported into Statistical Package for Social Science
(SPSS) (IBM, Armonk, NY) and Stata (StataCorp LLC, College Station, TX) to generate
descriptive statistics, including the comparative prevalence of significant ratings on BPRS
items and factors relating to physical health and demographics of the sample interview population as compared to: the IMU population, the overall state prison population, and the overall
population of the state itself. Fisher’s exact test and McNemar’s test were performed to evaluate
the relationships between BPRS ratings across housing location, time, and race/ethnicity; chi
square tests of homogeneity were performed to compare racial/ethnic distributions in the
IMU population, the general prison population, and the Washington state population. The
demographic data utilizes a confidential data file from the WADOC.
Transcribed interviews were analyzed using Atlas-ti (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany). Six team members, who had also conducted interviews,
engaged in an iterative and recursive coding process. Consistent with the tenets of constructivist
grounded theory, coders inductively explored how participants make meaning of their experiences (here: their time in solitary confinement) [63, 64]. This process included initial, line-byline open-coding of a subset of transcripts, which generated a list of 214 codes, grouped into 11
major categories (e.g., Health) with sub-themes (e.g., physical health) [63]. Some of these initial
codes and categories corresponded with specific questions on our interview instrument (most
relevant for the instant analysis: question 29 concerned medical “kites,” and questions 30, 31,
and 38 concerned physical health and somatic concerns). However, open-ended questions also
yielded responses related to these topics and were so coded. Given the constraints of the prison
setting (in-person contact is expensive and time-consuming; mail contact is not confidential
because of prison censoring policies), participants have not provided systematic feedback on
their transcripts or our findings. However, the year-two interviews did give research team members an opportunity to discuss year-one themes with participants.
All quotations presented in this paper were initially identified in the first phase of our coding process by one of three (out of our initial 214) codes: “somatic concerns,” “physical health,”
or “kites” (the standard, slang term for a paper form handed to a correctional officer to request
medical attention). Two coders then used intermediate focused coding techniques to

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re-code these 319 quotes, exploring the relationship between solitary confinement conditions and policies and physical health problems, “transform[ing] basic data into more abstract
concepts and allowing the theory to emerge from the data” [64 p. 5].
Notes from reviewing participants’ paper medical files corroborate details from the qualitative analysis that systematically anchors this data. Each participant has been assigned a pseudonym and, because we are also exploring the racially disparate impact of the health problems we
identify, we specify each quoted participant’s self-identified race or ethnicity. We linked quotations to specific racial/ethnic identities only after quotations were selected for inclusion in this
manuscript, as representative of the themes we identified in coding.

Results
In total, 225 prisoners in IMU (62%), responded to our in-person survey. The refusal rate of
initial interviews was 39% (67 out of 173 approached), comparable to similar studies of prisoners [15, 58, 59, 65]. The drop-out rate of our sample for the one-year follow-up interviews was
comparable to other studies at 25%: there were 4 refusals; 21 institutional, out-of-state, and
parole transfers precluding follow-up; and one death [58–61]. Our random sample of 106 (allmale) IMU prisoners reflects a mean age of 35; mean stay of 14.5 months in IMU; mean of 5
prior convictions resulting in prison sentences. Among our participants 42% were white; 12%
were African American; 23% were Latino; 23% were “Other.” There were no significant differences between our participants and all people held in IMU at the time of our sample. People in
the general prison population at the time of our sample are notably different as they are older,
less violent in terms of criminal history, serving shorter sentences, less likely to be gang-affiliated, and less likely to be Latino than those held in IMU [20]. (We discuss racial differences
across these populations further in the final results sub-section.)

Prevalence of somatic concerns
As an initial basis for describing physical symptoms experienced in solitary confinement, we
present a quantitative analysis of the prevalence of somatic concerns in our random sample of
106 people held in IMU, and the variability of these concerns across time and housing location.
In 2017, 15% of participants reported having clinically significant (formally defined as a severity of 4 or higher out of a possible 7) somatic concerns (formally defined as “concern over present bodily health”) on the BPRS assessment [21]. In the 2018 re-interview sample, of the 80
respondents re-interviewed in the second year of the study, 12.5% reported clinically significant ratings of somatic concern.
While ratings of clinically significant somatic concern mostly varied within participants
over time, our analysis indicated some persistence of somatic issues across the two assessment
periods. Of those who reported clinically significant somatic concern in 2017 and who were
re-interviewed in 2018 (12 respondents; 4 were unavailable for re-interview), 25% (3 respondents) indicated a persistence of clinically significant somatic issues in 2018. An exact McNemar’s test revealed no statistically significant relationship between the proportion of
respondents reporting clinically significant somatic concerns in 2017 and 2018 (p = 0.80).
In the initial 2017 assessment, all study subjects were housed in IMU. At the time of reinterview in 2018, 52 respondents had moved into the general prison population, while 28
remained in IMU. Of those who were still in IMU in 2018, 21% (6 of 28) reported clinically significant somatic concerns, compared to just 8% of those housed in the general prison population (4 of 52). While the descriptive data appear to demonstrate higher proportions of somatic
concern in IMU settings, the difference was not statistically significant at the 95% confidence

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level (p = 0.09; Fisher’s exact test). No significant differences were observed in the distribution
of clinically significant somatic concern ratings across racial and ethnic groups.
Complementing the BPRS assessment data from the random sample of 106 individuals in
IMU custody, survey data collected from the full IMU population in 2017 further indicated the
prevalence of somatic concerns among this population. Of the 225 survey respondents, 63%
expressed health concerns; 48% were taking medication; 17% had arthritis; and 8% had experienced a fall in solitary confinement. Importantly for the analysis of emerging symptoms in particular, 82% replied “yes” to the question “Have you experienced any changes in yourself?”
while in the IMU. These survey results, like the BPRS somatic concern results, benefit from triangulation with our qualitative data.

Specifying physical symptoms
We identify three categories of physical symptoms people experience in solitary confinement,
each associated with different aspects of IMU housing: symptoms associated with deprivation
conditions, symptoms associated with deprivation policies limiting access to healthcare, and
chronic musculoskeletal pain exacerbated by the intersection of deprivation conditions and
deprivation policies. In each category, we analyze how the institution of solitary confinement
shapes both physical health outcomes and perceptions of health for people housed in solitary
confinement, revealing both the mechanisms of physical health deterioration and the accentuated comorbidity of physical and mental health in solitary confinement.
Deprivation conditions. Our participants described a range of physical ailments directly
connected to the conditions of their confinement, especially the various deprivations of movement,
provisions (from food to toiletries), and human contact inherent in the institutional restrictions
defining solitary confinement. Skin irritations and weight fluctuations were the most common of
these; participants experienced both as co-morbid with anxiety and other health issues.
Participants described rashes, dry and flaky skin, and fungus developing in isolation. They
understood these conditions as being directly associated the poor air and water quality, irritating hygiene products, and lack of sun exposure inherent to their conditions of solitary confinement. People in the IMU (unlike those in the general prison population) usually cannot
purchase or trade for alternative, higher-quality hygiene products; their cells have limited natural light (at best, a window far above eye-level; at worst, no window); and even the exercise
areas frequently have limited natural light. Indeed, research has documented how isolation can
cause vitamin D deficiency due to lack of natural light exposure [66].
As Joseph (white) explained, an ostensibly trivial physical problem, like dandruff, can
inspire a sense of helplessness in the IMU:
Well I try not to [think about] what happens to my body. . .Because you’re going to obsess
on it probably. . .Minor things become huge when you’re in segregation, and so, something
that you–you as being free in society can alleviate by going to, you know, to [the store] or
whatever, and just get a dandruff shampoo. You can’t do that here. And kiting medical and
telling them “Hey, I have a severe problem with dermatitis, and my head’s itching and I’ve
got bleeding scabs on my head,” or whatever the case may be, there’s nothing that we can
do here. You’re SOL [shit out of luck].
Joseph’s inability to treat his skin irritations himself led to both helplessness and obsessiveness, further exacerbating the discomfort and potential health consequences of the issue. This
case illustrates how a free person’s flaky skin or minor embarrassment becomes a potentially
severe medical problem in solitary confinement, entailing bleeding scabs on the scalp.

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Participants frequently experienced fluctuations in body weight and, as with skin irritations,
connected these symptoms to conditions inherent to solitary confinement. What started as
simple observations about diet, exercise, and appearance often turned into analyses of the
impact of conditions of confinement on physical, as well as mental health. Simon (Black) discussed being “real worried” about his weight:
The only reason I know they’re not really giving us the calorie needs they’re supposed to
give us, is because I feel like I’m losing more muscle than I am fat. And to lose more muscle
than fat is because you’re not getting the nutrients that you need.
Not only is weight loss a significant source of anxiety for Simon, but he connects the deprivations of confinement–the lack of nutritious food and sufficient calories–to physical changes
in his body. Whether his explanation is correct, or simple lack of physical activity is more likely
to explain the changes accurately, IMU confinement ostensibly produced the change.
Participants also described restricting their own dietary intake, beyond the already limited
rations (usually calculated to meet the minimum daily calorie intake standards), for a variety
of reasons, from the quality of the food to their emotional state. Michael (Latino) described
being suspicious of staff having tampered with his food: “I got my breakfast bowl and there
was a tear on the plastic. [. . .] Sometimes your mind plays tricks on you, like they’re trying to
poison you or something.” While Michael noted that his suspicions were likely just in his
mind, Philip (Black) asserted: “They was poisoning my food–they control everything. They
can even manipulate the water. I’m so fucking serious; this place is highly technologically
advanced.” For those like Michael and Philip, psychological states associated with the conditions of confinement (e.g., suspiciousness, paranoia, and potentially psychosis) caused them to
restrict their food intake, resulting in weight loss. Indeed, both Michael and Philip had documented diagnoses of mental illness in their medical files; bipolar disorder and undifferentiated
schizophrenia respectively. Food restrictions can, of course, lead to more imminently dangerous conditions, such as dehydration, electrolyte imbalances, or renal failure–none of which are
likely to be subject to objective evaluation in the IMU, as we discuss further in the next subsection on the impacts of deprivation policies.
Some prisoners made a more direct connection between their mental health, their dietary
intake, and their physical health. For instance, Kai (Native American), said:
I don’t work out because I have a problem breathing . . .This is the first time I’ve ever done
a program [IMU term] where I’ve felt like I was breaking. Because before I’d be working
out. . . Now, I’m stuck in this . . .I’m battling mentally with everything going on. Which
affected my body, effects my eating sometimes. I’ll just take the [food] tray but I’ll flush the
stuff down the toilet.
As Kai suggests, in the IMU, exercise functions not only as a means to practice physical fitness, but also to provide structure for people to manage both their days and the mental strain of
being in isolation. When asked a general question, like “how are you doing in the IMU?” many
participants, like Kai, referenced whether or not they were engaging in exercise as a way to
gauge how they were faring overall. People like Kai shared feelings of lethargy, or feeling too
overwhelmed to do anything but lie around all day, induced by long periods in solitary confinement. Their weight fluctuated during these cycles: going down with regular and social exercise
routines, going up with exercise-induced injuries or periods of lethargy. Concerns around exercise, diet, and the associated body weight fluctuations, like concerns with skin irritations, highlight the interdependence of physical and mental wellbeing for prisoners in the IMU.

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Deprivation policies. Our participants described multiple situations in which official
IMU policies and unofficial IMU practices exacerbated their physical ailments, especially their
chronic health problems. Such policies and practices included the prioritization of security
over care in emergency situations, disruptions in care upon transfer into the IMU, and overwhelming administrative hurdles to accessing care in the first place. If prisons are largely
unequipped to provide the appropriate care and environment for chronic medical problems
[67, 31], our findings reveal both the specific mechanisms by which solitary confinement policies amplify the usual bureaucratic challenges of accessing healthcare in prison and the kinds
of physical health problems that go unaddressed as a result.
First, in cases of medical emergencies, people housed in the IMU have response buttons in
their cells they can press to alert staff. However, many of the people we interviewed both
doubted whether staff would respond swiftly enough in an actual emergency and worried
about being punished with additional time in the IMU for activating an emergency response,
if medical staff ultimately deemed their problem non-emergent. Indeed, prisoners perceived
IMU policies as systematically prioritizing incapacitation over medical attention. Carl (white)
described an incident where he experienced delayed care and was pepper sprayed after having
suffered from a seizure, all because he was unable to comply with orders to stand following the
episode:
I had a serious seizure. And I was laying on the floor, and I had defecated. I was laying in a
puddle of puke. . .Well, [the guards] had come to the door, and I guess they had called medical. . .and they were standing there for 45 minutes yelling, “Stand up and cuff up so we can
give you medical attention.” They did not pop the door and go in there and give me medical
attention. And so, unknown to me, they popped the cuff port, and they sprayed OC [pepper
spray] in there. And then they came in. They noticed that I was unconscious, and finally a
nurse looked at my medical file and she’s, like, “he’s epileptic.”
In the tense environment of the IMU, where staff manage people with histories of violating
prison rules, assaulting staff, and, often, serious mental health needs, immediate security concerns readily take priority over assessing medical histories and providing healthcare.
Second, simply being transferred into the IMU often disrupted care in dangerous ways. For
instance, Julian (Hawaiian) described how, when he was transferred into a new solitary confinement unit, he had to restart the process of seeking treatment for (and even simple acknowledgement of) recurring kidney stones. Whereas he had fought and been able to receive x-rays
and medication to help manage his kidney pain at his prior institution, he now found this fight
to be futile at his new facility: “They’re just going to take me out of room, take me over there to
medical, and they’re going to be like, oh here’s the hot water or hot bag or whatever.” And
Tony (Native American/white) described a battery of physical and mental health issues–an
enlarged prostate, a painful cyst that needed to be surgically removed, varicose veins, “chronic
suicidal thoughts,” anxiety, and depression–all requiring medications, which he had difficulty
maintaining access to in the IMU. For instance, he described how both his Amitriptyline,
which partly treated his periodic limb movement sleep disorder, and his seizure medication,
Dilantin, were both discontinued in the IMU, resulting in serious injuries to his foot and head.
Third, a number of bureaucratic hurdles and barriers discouraged people in the IMU from
attempting to access healthcare at all, even in potentially life-threatening situations. In order to
see a medical professional, people isolated in the IMU must fill out a paper request (a “kite”)
and hand it to a correctional officer passing by, or report a concern to a nurse, who makes
daily rounds passing by each cell in the IMU. The medical response happens either “cellfront,”
with the person talking to the medical professional through his cell door, in earshot of others

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held in solitary confinement, or “by escort,” with the person in handcuffs and leg-cuffs, if not
also belly chains and a hood, usually accompanied by at least two to four correctional officers,
to a medical treatment area. Vitamins and over-the-counter medications like Tylenol, or asneeded medications like asthma inhalers, are kept outside of the cell and available only at specified times, or, again, by paper kite request. Throughout WADOC, people must pay $4 for
non-emergency medical care (unless they are indigent, in which case WADOC provides care
without a co-pay), but people held in the IMU have more restrictive caps on their overall
spending for any needs, including healthcare, food, and toiletries, proportionally raising the
relative cost of seeking care for non-emergency symptoms.
These policies, in combination with negative perceptions about the quality of care available
to them, dissuaded participants from seeking medical services. Deon (Black) described new
and unfamiliar “breathing problems” and rising “blood pressure” in IMU, but felt that seeking
medical attention would be useless:
It’s pointless for me to knock on the window and ask the nurse, “Hey, nurse, do this.”
Because every time I knock on the window–it is pointless because the only thing the DOC
wants is money. It is money. . . I think people in the cell should be important. . . And it’s a
long time but I’d just rather wait till I get out.
Later in the interview, Deon links his rising blood pressure to his isolation: “I never had
blood pressure problems until I went to this IMU.” Because Deon does not expect to be treated
with care or dignity, he avoids medical treatment. As a result, his new breathing issues and rising blood pressure went unnoticed by medical staff, and Deon did not find out the cause.
Blake (white), described experiencing unfamiliar physical health symptoms in the IMU, for
which he was also hopeless about receiving any medical assistance:
I’ve been told I have a heart murmur, but for, like, last two weeks. . .I’ve been feeling my
heart, like, feeling weird like it flutters once in a while. . .[I] just don’t tell nobody. . .because
they won’t do nothing about it unless you’re actually having a heart attack, or unless you
declare a medical emergency. . .they’ll pull you out, take your vitals, and then charge you 4
bucks. . . If I have a heart attack or don’t have a heart attack, it don’t matter.
Not only did Blake, like Deon, doubt whether a prison medical provider would believe him
and try to help him, but he was further dissuaded from seeking treatment by the $4 institutionally-imposed cost for non-emergency treatment. Four dollars is arguably worth much more in
prison that it would be even to a destitute person on the outside, and worth more still to someone in the IMU. Under WADOC policy, people in IMU are only allowed to spend $10 per
week on store items, such as coffee, pastries, and deodorant. The $4 medical fee would absorb
nearly half of this weekly spending cap. Blake might have had clinically insignificant, subjective
palpitations, or the onset of atrial fibrillation following an undiagnosed myocardial infarction;
his confinement status rendered clarification functionally unavailable.
Like many other participants, Deon and Blake expressed a sense of futility about seeking
medical assistance while in the IMU, dissuaded by bureaucratic hurdles from perceived dismissiveness and indignity (exemplified in the problem of dual loyalty [67]) to actual costs of
care. Futility, in turn, led to non-evaluation of emerging medical problems. Still, Deon and
Blake expressed a passive acceptance of their situation: “it’s pointless,” and “it don’t matter.”
This hopelessness reflects a precarity unique to solitary confinement: wondering whether medications would be provided and refills renewed, whether the severity of ailments would be
acknowledged, and whether medical emergencies would be addressed or, instead, treated as

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security threats. As our participants’ experiences suggest, solitary confinement carries the
additional punishment of substandard access to health care.
Exacerbating musculoskeletal pain. Participants spoke frequently about one specific,
chronic ailment in solitary confinement: musculoskeletal pain. The experiences of people in
solitary confinement with chronic musculoskeletal pain reveal how the prior two categories of
symptoms we analyze, those associated with deprivation conditions and those associated with
deprivation policies in solitary confinement, interact to exacerbate physical health problems.
While participants attributed their musculoskeletal pain to a range of causes from physical
injury to arthritis, bursitis, and sciatica, they consistently experienced this pain as untreated
and interfering (physically and mentally) with even those few, limited activities available to
them in solitary confinement.
For instance, Victor (Latino) described his frustrations with attempts to get care, let alone
relief, from the pain of his sciatica:
I’ve been told I have nothing wrong with me, but I have been hurt, and they took x-rays of
my back, and they found that the disks are in there or something that’s triggering some
nerves. And I still got a little bit of time left, and they just opened up an Ibuprofen right
now. And that stuff doesn’t work. So, what can you do?
Victor’s medical file highlights persistence of chronic pain in his back and hips and notes
that he avoided sitting down for longer than 5–10 minutes. Not only did participants describe
untreated pain, but they described the anxiety associated with the lack of treatment. Isaac
(Black/Latino) described how he experienced both quad and hamstring pain in the IMU, and
how this escalated his physical health concerns: “I’ll start thinking like oh, I’m laying in bed
too much. Maybe my muscles are starting to rot, you know, eating on themselves.” In a similar
sentiment, Tim (white) stated, “My body is like–I can’t explain it. Like my skeleton, feels like
my skeleton’s broken or something.” While Victor must bear persistent pain and the anxiety
that he will likely have to continue to suffer, Isaac and Tim’s experiences are more reflective of
somatization, or the expression of psychological distress through physical symptoms [69].
These participants highlight the complex comorbidity between musculoskeletal pain and mental health in isolation, an inverse experience of physical pain. Tyler (white), discussing his scoliosis, made a direct connection between his untreated pain and his mental health: “Mental
health and things that go through your head just because of this, when you got pain shooting
up into your brain, and you guys aren’t fixing it.”
Pain and anxiety, in turn, interfered with other aspects of IMU existence. Craig (white)
described how an untreated knee injury was causing him “moderate to severe pain,” in combination with anxiety about how he would re-enter society when released directly from solitary
confinement; together these experiences interfered with his everyday activities, including his
ability to communicate with his family. “I was in the middle of actually writing my mom a letter, and I was going to tell her about, you know, they still haven’t done anything with my
knee. . .I couldn’t write the letter anymore. I just got so mad. I was so mad I really couldn’t
even focus on anything.” Craig’s medical file affirms his complaint, documenting knee swelling and chronic extension tendonitis, but also indicating no abnormalities were found.
People living in solitary confinement are left with very few options to effectively manage
persistent pain, which appears to foster more maladaptive behavior, such as rumination, stress,
and despair, within a highly restrictive and stimuli-depleted environment [68–71]. Along with
bearing the institutional monotony, medical precariousness, and procedural strictures of solitary confinement, one’s own body becomes a challenge to withstand [72, 73].

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Racial/Ethnic disproportionalities
We now turn to reporting the race and ethnic disparities in the Washington state prison population overall (compared to the statewide adult population), and in solitary confinement specifically (compared to the general prison population). These disparities suggest that the
various mechanisms by which solitary confinement impacts health and well-being are likely to
be disproportionately experienced across race and ethnic lines.
We analyze administrative data provided by WADOC and Census Bureau population estimates. Black, non-Latino individuals represented only 3.7% of adults in Washington state in
2017, but they comprised 17.9% of the general prison population [74]. Similarly, Latino individuals represented 10.3% of the statewide adult population, but 13.6% of the prison population. Conversely, both White, non-Latinos and Asian/Pacific Islanders, Native Americans, and
mixed-race individuals (grouped within “Other/Unknown”) were somewhat under-represented in the general prison population relative to the statewide adult population (see Fig 1).
Differences in racial and ethnic composition of the general prison population and the statewide adult population are statistically significant (p < .001; chi-square test for homogeneity).
Within prison walls, we find evidence of further racial and ethnic disproportionalities in
housing placement. Comparing those housed in restrictive IMU confinement to those housed
in the general population, we find that prisoners who self-identify as “Latino, Any Race” and
“Other/Unknown” ethnicity are over-represented in IMU. To characterize the scale of differences in the racial/ethnic composition of the IMU and general prison populations, we calculated disproportionality, or prevalence, ratios as the proportion of each racial/ethnic group in a
given population, divided by the proportion of that racial/ethnic group in the reference population. Here, Latinos are over-represented within the IMU participant group by a factor of 1.7
relative to their representation in the general prison population, and those grouped in the
“Other/Unknown” category are over-represented in the IMU sample by a factor of 2.6, relative
to the general prison population. Conversely, White, non-Latino individuals are under-represented in the IMU sample relative to the general prison population. Likewise, and in contrast
to the gross disproportionality documented in the general prison population, Black, nonLatino individuals are moderately under-represented in the IMU sample, relative to the general prison population: 11.3% of the IMU sample identified as Black, non-Latino, compared
with 17.9% of the general prison population. The difference in the racial and ethnic composition of those in long-term solitary confinement compared with the general population was statistically significant (p < .001; chi-square test for homogeneity).

Discussion
A popular analogy likens prison to a chronic illness: it disrupts daily life, interrupts routines
[72], spreads risk like a contagious disease [75], and models like an epidemiological problem
[76, 30]. While the study of the physical effects of incarceration has developed over the last
decade, there is a serious gap in the literature in understanding the experiences and outcomes
of physical health in isolation. We are just beginning to understand the medical correlates of
solitary confinement, their comorbidity with mental health, and overall implications for prisoners’ suffering [72]. Integrating surveys, interviews, BPRS scores, medical and disciplinary
file reviews, and administrative data, the scale and array of our research represents one of the
more robust studies of solitary confinement to date [20]. The multi-method research presented
here offers a first step not only towards understanding some typical medical problems of solitary confinement, but also towards understanding the analytical challenges of an environment
in which physical and psychological problems are immediately concomitant, and objective
clarification is often unavailable.

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100%
9.3%

13.8%
90%

13.6%

10.3%

80%

70%

17.9%

22.6%
60%

50%
11.3%
40%

30%

20%

10%

0%
Washington State Population,
18 and Older (N=S,759,927)*

■

White, Non-Latino

■

IMU Sample
(n=106)*

General Prison Population
(N =15,867)t

Black, Non-Latino

■

Latino, Any Race

■

Other/Unknown"
�

Fig 1. Racial and ethnic composition of IMU sample, general prison population, and Washington State, 2017. U.S. Census Bureau,
Population Division. Annual Estimates of the Resident Population by Sex, Age, Race, and Hispanic Origin for the United States and
States: April 1, 2010 to July 1, 2017. 2018 Jun. † Authors’ calculations. The total prison population file included 17,943 individuals in
DOC prison custody on July 1, 2017. For comparison purposes, the “general prison population” excludes those returned to prison on
violations of release or sentence conditions, those in an IMU unit on the index date, and those on a maximum custody status (n = 1,970),
as well as those in the IMU sample (n = 106). ‡ No significant differences in racial/ethnic composition were found between the IMU
sample and larger IMU population on the index date using race/ethnicity data from DOC. These data reflect self-reported race/ethnicity
during participant interviews. ^ Other/Unknown includes individuals of two or more races, Asian/Pacific Islander, Native American/
Alaska Native, and unknown race/ethnicity information.
https://doi.org/10.1371/journal.pone.0238510.g001

We find that solitary confinement constitutes not just a mental but also a physical health
risk. It exacerbates well-documented physical health “symptoms” of incarceration, from disruptions of daily life and routines, to undiagnosed, untreated, or mis-treated ailments [1, 30,
38]. These initial symptoms, in turn, produce other risks: to the extent respondents are accurately reporting weight fluctuations in solitary confinement, this physical symptom has detrimental health implications; weight fluctuation, itself, is associated with adverse cardiovascular
and psychological outcomes [77, 78]. Likewise, musculoskeletal pain increases multimorbidity,
and its sequelae are tightly unified in their impact on disability [79].
These health concerns likely have a grossly disparate impact on communities of color: just
as incarceration is a health stratifying institution for prisoners, their families, and communities, so, too, does solitary confinement appear to exacerbate racial health inequities. While we
find that Black, non-Latino individuals are moderately under-represented in the IMU sample,
relative to the general prison population, we find that Latino and Other/Mixed Race prisoners
are disproportionately over-represented in solitary confinement in WADOC, just as other

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studies have documented disproportionately high representations of racial and ethnic minorities in other states’ uses of solitary confinement [22, 41, 43]. We further find that prisoners of
all races describe similar physical health challenges and complaints while in solitary confinement. In sum, people of color face a disproportionate risk of being placed in solitary confinement; such racial disparities, in turn, mean that the physical health symptoms associated with,
or possibly caused by, these conditions of confinement are likely to fall disproportionately on
certain groups. Though we do not explore other risk factors for over-representation in solitary
confinement in this paper, we and others have documented serious mental illness [20, 80],
transgender identification [81], and pregnant women [82] as particularly vulnerable to both
incarceration and solitary confinement, suggesting additional sub-groups who might face disproportionate and unique risks of physical health problems in solitary confinement.
If anything, the evidence we present here understates the prevalence and intensity of the symptoms we document. First, Washington State is a progressive system actively engaged in both limiting the application and the duration of solitary confinement and developing measures to mitigate
its harmful effects, from better mental health training for correctional staff to more sustained
group contact for prisoners in IMUs; conditions, and their physical effects, are undoubtedly
worse in many, if not most, other states [20, 42, 44]. Second, the BPRS somatic concerns scores
we present focus on the two weeks prior to assessment, so likely underrepresent the cumulative
incidence of somatic concerns in the study sample over time. Third, our exceptionally large random sample size for an in-depth, mixed methods study of a solitary confinement population was
still not powered to establish statistically significant differences between interview subjects in the
IMU in year one (2017) and those out of the IMU in year two (2018)–otherwise important comparison groups for understanding differences in either somatic concerns measures, or physical
symptom specifications. Fourth, both the Washington state population and state prison population have proportionately more white people than some other states and prisons, where racial disparities in both prison and solitary confinement may be even more significant.
While our findings do not establish either how prevalent the symptoms and mechanisms of
suffering we specified are among people in solitary confinement, as compared to the general
prison population, or whether solitary confinement in fact directly causes these symptoms,
recent research suggests that at least some of the symptoms our respondents reported, like
hypertension, are significantly associated with long-term isolation [83, 45]. Although the evidence is clear that solitary confinement poses serious health risks [54, 45], our research highlights the importance of continuing to document and analyze these risks, especially from a
multi-method perspective triangulating administrative population-level data with objective
scales like the BPRS, subjective descriptions of experiences from surveys and interviews, and
corroboration from medical file reviews.
First, documenting physical health problems provides a critical means to elucidate the severity of deprivations in treatment, environmental conditions, and exercise and nutrition [84, 85]
inherent in solitary confinement. If incarceration is experienced fundamentally through control
and restriction of the body, this is all the more true in solitary confinement, where prisoners are
subjected to extreme forms of control while being entirely reliant on others for accessing basic
necessities, from food to healthcare. Our participants experienced the deprivations of solitary
confinement as exacerbating their health problems, which shaped their health experiences as
punitive. Otherwise medically trivial conditions quickly become grave in solitary; “dandruff”
can become a bleeding scalp wound, a four-dollar co-payment blurs the difference between subjective palpitations and an unstable arrhythmia, and unused muscles “rot.” Physical suffering
reveals itself to be a crucial dimension of experience in solitary confinement.
Second, to the extent physical symptoms, in particular, are more familiar, more readily
labeled, and less stigmatized than mental health issues, they may provide a window into other,

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less physically tangible pains of confinement, in solitary or elsewhere [84, 85]. The visuality of
spectacular forms of suffering in carceral institutions is only made possible by and through
mundane phenomenon that our participants elucidate through their discussions of everyday
physical experiences [86]. Indeed, attending to people’s physical health in solitary confinement
reveals the irreducible relationship between the body, mental health, and highly restrictive
conditions of confinement. Whether they exercise to the point of physical debilitation to keep
their minds busy, refuse to eat because they do not trust their food is safe, or avoid medical
care out of a hopelessness of being treated with dignity, the physical and psychological are intimately bounded in people’s experiences in prison. Examining physical suffering in solitary
confinement, then, becomes a tool for understanding suffering in prison more broadly, and
especially the comorbidity of physical and mental suffering.
Third, the challenges we document in identifying and specifying physical symptoms in solitary confinement reveal not just the interrelationship between symptoms, conditions, and policies, but institutional mechanisms exacerbating both the identification and treatment of
physical problems in prison. In many cases, our respondents had no hope of establishing what
was physically wrong with them, let alone whether the conditions of their confinement caused
the physical ailments, because they either could not get or avoided medical treatment. While
both community standard and continuity of care is an issue in prison generally [67], solitary
confinement widens these service gaps. The phenomenon of dual loyalty, which describes how
the patient-provider relationship within prison can be subsumed by correctional directives of
control and mistrust of incarcerated people [67], is acutely relevant in the context of solitary
confinement, where both control and mistrust are especially prevalent [87, 88].
In sum, examining solitary confinement and documenting its affects provides an important
magnifying lens for understanding prison and its affects more broadly, not only in elucidating
the mechanisms of harm, but also in developing responses to mitigate these harms. Ninety-five
percent or more of all prisoners will eventually return home to our communities [4, 5]; and
many will have spent time in solitary confinement. Nearly one-in-five people in prison spends
time in solitary confinement each year, and one-in-ten spends 30 days or more in these conditions [3]. These numbers will only increase in the face of the global COVID-19 pandemic,
which has justified facility-wide “lockdowns,” imposing restrictions similar to those in solitary-confinement, in prisons across the United States, as well as actual solitary confinement
placements for infected and exposed prisoners [89]. To the extent that solitary confinement
undercuts treatment and care in and beyond prison, it undermines the public health of those
incarcerated and those returning to our communities.

Supporting information
S1 Text. IMU survey.
(PDF)
S2 Text. Interview instrument.
(DOC)
S1 Checklist. Consolidated criteria for reporting qualitative studies (COREQ): 32-item
checklist.
(DOCX)
S1 Quotations.
(DOCX)

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Author Contributions
Conceptualization: Justin D. Strong, Keramet Reiter.
Formal analysis: Justin D. Strong, Keramet Reiter, Gabriela Gonzalez, Rebecca Tublitz.
Methodology: Justin D. Strong, Gabriela Gonzalez, Rebecca Tublitz.
Project administration: Justin D. Strong.
Writing – original draft: Justin D. Strong, Keramet Reiter, Gabriela Gonzalez, Rebecca
Tublitz, Dallas Augustine, Melissa Barragan, Kelsie Chesnut, Pasha Dashtgard, Natalie
Pifer, Thomas R. Blair.
Writing – review & editing: Justin D. Strong, Keramet Reiter, Dallas Augustine, Melissa Barragan, Kelsie Chesnut, Pasha Dashtgard, Natalie Pifer, Thomas R. Blair.

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