The Spiral of Risk: Health Care Provision to
Incarcerated Women

Prepared by
National Council on Crime and Delinquency

March 1, 2006

NATIONAL COUNCIL ON CRIME AND DELINQUENCY
Headquarters Office 1970 Broadway Suite 500, Oakland, CA 94612
(510) 208-0500 FAX (510) 208-0511
Midwest Office 426 S. Yellowstone, Suite 250, Madison, WI 53719
(608) 831-8882 FAX (608) 831-6446

TABLE OF CONTENTS
INTRODUCTION ...................................................................................................................5
Rights and Legal Regulations ..................................................................................................................5
Explosion of Incarceration......................................................................................................................5
Nature of Women’s Crimes ....................................................................................................................5
Health Problems .......................................................................................................................................6
Obstacles to Health care..........................................................................................................................6
Disparity Among Facilities ......................................................................................................................7
Unique Characteristics .............................................................................................................................7
Statement of the Problem........................................................................................................................7
METHOD .................................................................................................................................9
NCCD’s Women and Prison Project.....................................................................................................9
Paper Focus and Research Objectives...................................................................................................9
Women and Prison Advisory Panel .......................................................................................................9
Sample ......................................................................................................................................................10
Data Collection and Analysis ................................................................................................................10
FINDINGS.............................................................................................................................. 11
I. Process of Access to Health Care....................................................................................................11
Co-pay Form ...........................................................................................................................................11
Sick-call and Hot Meds ..........................................................................................................................11
Emergency Care......................................................................................................................................12
Five Dollar Co-pay Charge....................................................................................................................12
II. Gaps in Current Service Provision ..................................................................................................12
Mental Health..........................................................................................................................................12
Treatment ............................................................................................................................................13
Reproductive Health ..............................................................................................................................13
Physical Health........................................................................................................................................14
Chronic Illness ....................................................................................................................................14
Infectious Disease ..............................................................................................................................14
Treatment ............................................................................................................................................15
Medications .........................................................................................................................................15
Dental and Vision Services ...............................................................................................................15
III. Continuity of Health Care ...............................................................................................................15
Preventive Care .......................................................................................................................................16
Nutrition and Exercise ......................................................................................................................16
Routine Screening ..............................................................................................................................16
Education ............................................................................................................................................16
Follow-up Care........................................................................................................................................16
Transitional Care.....................................................................................................................................17
Communication between Staff and Institutions.................................................................................17
IV. Quality of Staff ..................................................................................................................................17
Positions...................................................................................................................................................17
Distribution of Resources......................................................................................................................18
Attitudes ...................................................................................................................................................18
Qualifications...........................................................................................................................................18
Administrative Limitations ....................................................................................................................18
V. Cultural Competency .........................................................................................................................19
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Language barriers....................................................................................................................................19
Racial and Ethnic Breakdown of Staff ................................................................................................19
RECOMMENDATIONS AND DISCUSSION.....................................................................20
I. Decarcerate and Promote Alternatives to Incarceration ..............................................................20
Special Populations.................................................................................................................................20
Legislative Reform..................................................................................................................................21
II. Improve Services inside Correctional Facilities .............................................................................21
Improve Standards in Health Care Services .......................................................................................21
Eliminate Administrative Barriers ........................................................................................................22
Improve Quality of Staff........................................................................................................................22
III. Support Continuity of Care .............................................................................................................23
IV. Promote Cultural Competency .......................................................................................................23
CONCLUSION.......................................................................................................................24
REFERENCES .......................................................................................................................25
APPENDIX: INTERVIEW INSTRUMENT........................................................................26

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ABSTRACT
By law, prisoners in the United States have a fundamental right to receive adequate health care.
However, most prisoners in this nation face numerous obstacles when attempting to receive quality
health services. This is especially true for incarcerated women, who suffer from physical and mental
health disorders at rates higher than incarcerated men, yet receive fewer targeted services.
The state of California leads the nation in the number of women it incarcerates, second only to
Texas. The vast majority of these women are in custody for nonviolent, drug-related offenses, and
few receive adequate health care.
Female offenders commonly face a wide range of serious health problems including substance
abuse, infectious disease, mental illness, hypertension, asthma, and diabetes. Their health problems
typically predate their involvement in the justice system, are often exacerbated while they are
imprisoned, and continue to deteriorate after release. Furthermore, the majority of women in
custody are racial and ethnic minorities, who receive inadequate or inappropriate health services that
fail to be culturally competent.
This paper presents the results of an intensive investigation of the health care delivery system for
women imprisoned in California. We characterize the current system for providing health care to
incarcerated women in California and address gaps in current service provision and cultural
competency. We conclude by outlining a strategy to improve quality and access of holistic health
care within the system and during transition back into the community.

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INTRODUCTION
Rights and Legal Regulations
By law, prisoners in the United States have a fundamental right to receive adequate health care. The
Constitution is meant to protect prisoners from cruel and unusual punishment, including the
unnecessary affliction of pain due to the denial of essential medical attention. When prisoners suffer
because of negligence of correctional staff and low-quality medical care, their rights are clearly
violated. State laws attempt to regulate provisions to health care services for inmates. In California,
penal code sec 6030 states that prisoners have the right to health care, sanitary conditions, and
advice from medical, dental, or mental health professionals. The California Code of Regulations
Title 15 outlines emergency and basic health care services and the California Department of
Corrections (CDC) Comprehensive Policies and Procedures, which is based on the Plata Settlement,
provides specific health care regulations. Correctional facilities are legally responsible for making
these provisions.
Explosion of Incarceration
On a national scale, the rate of increase in the number of incarcerated women has consistently
exceeded that of men for more than a decade (Amnesty, 1998). Much of this increase is due to
“tough on crime” policies and legislation enacted as part of the War on Drugs (Casey and
Wiatrowski, 1996). These policies have affected women disproportionately, because women are
more likely to be incarcerated for drug-related or petty, nonviolent property crimes. Before the
advent of mandatory minimums for drug sentences, these crimes would not have warranted
imprisonment, but now judges usually have few options. Without judicial discretionary authority,
sentencing ignores common mitigating factors for women.
California’s population of women inmates continues to grow as well. With over 10,000 incarcerated
women, California has the second largest population of women prisoners in the nation—most states
have less than 3,000. California prisons are overflowing with mothers (64%) and women struggling
with drug problems (80-85%). However, growth in health care for women has not kept pace with
the expansion in incarceration. Effective drug rehabilitation programs are rare in comparison with
the explosion of drug-related sentences. Only 15.2% of women participate in the substance abuse
treatment program for parolees (Little Hoover Commission, 2004). There is a growing gap between
the care that women need and the care that they receive. Therefore, it is essential to address these
obstacles and disparities and evaluate the effectiveness and quality of health care.
Nature of Women’s Crimes
The vast majority of women prisoners are confined for drug offenses, property crimes, and public
order crimes. Therefore, their sentences are relatively short, and they are soon released into the
community. Women parolees released in 2003 served an average of 14 months (Little Hoover
Commission, 2004). However, nearly 20% of women entering California prisons are parole violators
returning to custody for technical violations of their release conditions (Little Hoover Commission,
2004). In 1998, more than half of the returns of women to prison for parole violations were for drug
offenses (Hall, 2001). Women’s substance abuse problems are not being addressed in prison and,
therefore, contribute to future crime. Very few programs exist to effectively reintegrate inmates into

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the community. In 1997, the only federally-funded drug treatment program with an aftercare
component in California was Forever Free (Bloom, 1994).
The second largest group of women returned to prison for property crimes. In comparison to men,
more women were unemployed before they were arrested, and most leave prison without necessary
job training. Only 40% of women had a fulltime job before they were arrested compared to 60% of
men, and, while only 8% of men were on welfare, 30% of women received aid before they were
incarcerated (BJS, 1999). This cyclical nature of imprisonment is not preventing crime nor protecting
society, rather it is moving women in and out of prison through what is termed the “revolving doors
of justice.”
Health Problems
While in prison, few women receive adequate health care or treatment, and when they return to their
communities their health often deteriorates. Female offenders commonly face a wide range of
serious health problems including substance abuse, infectious disease, mental illness, hypertension,
asthma, and diabetes. In a study of 151 women inmates, 61% required medical treatment for one or
more problems and 45% required mental health treatment (Acoca and Austin, 1996). Even though
both men and women experience similar rates of substance abuse problems (80-85%), women have
higher rates of using drugs regularly the month prior to arrest and while the crime was committed
(Little Hoover Commission, 2004). Women’s prisons in California also have a higher percentage of
inmates who are HIV positive, 3.5% versus 2.2% (Little Hoover Commission, 2004). Yet, many
prisons lack quality services and are unable to accommodate these health needs, so many women
continue to live without necessary care (National Institute of Corrections, 2002). Moreover, heath
problems that are not cared for during imprisonment often get worse and continue to be untreated
after release. Outside of prison, these women frequently experience extremely limited access to
health care. Their health problems typically precede their involvement in the justice system, are often
exacerbated while they are imprisoned, and continue to deteriorate after release.
Obstacles to Health Care
Most prisoners in the United States face numerous obstacles when trying to access quality health
services. First, institutional policies often deliberately limit inmates’ access to get medical assistance.
Many prisons have implemented the “sick call” system, which requires inmates to stand in long lines
while they wait for a doctor. This system deters prisoners who are ill or physically unable to wait in
line from seeking help. Since security procedures limit prisoner’s ability to access medicine, or even
basic necessities for self-care, minor problems are often left untreated, leading to more dangerous
and costly health care problems (Acoca, 1998). Second, qualified doctors are less likely to work in
prisons due to undesirable conditions and less pay (The Correctional Association of New York,
2000). Third, a lack of cultural competency limits the availability and quality of medical assistance to
a large portion of women in prison. For example, almost 75% of incarcerated women in federal
prisons are minorities. (Thirty-five percent are African American, 32% Hispanic and 4% other (BJS,
2000).) Without translation services, women who do not speak English are unable to fill out
necessary forms, communicate their health problems, or fully understand the diagnosis and
treatment recommendations (Stoller, 2001).

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Disparity among Facilities
Women are especially affected by these obstacles because they suffer from physical and mental
health disorders at rates higher than incarcerated men, yet receive fewer targeted services. The
percentage of women inmates who use the “sick call” system is double that of men. Similarly,
women receive counseling and psychotropic medications twice as often as men (Little Hoover
Commission, 2004). Women inmates represent only a small percentage of the overall prison
population in the US, about 6%. They have fewer facilities, fewer programs, and fewer adequate
opportunities to engage in meaningful rehabilitative activities (BJS, 2000). In a survey of 52
correctional departments nationwide, only 27 provided substance abuse treatment programs for
women, only 19 had domestic violence programs, only 9 offered programs for sexual abuse victims,
and only 9 had programs for women’s health education (Amnesty, 1998).
Unique Characteristics
Rigid sentencing guidelines fail to recognize the inherent differences between men and women
involved in the justice system. Women prisoners have unique characteristics and specific needs. The
plight of incarcerated mothers is of special importance. Half of the women imprisoned in California
were taking care of their children at the time of their arrest, and two-thirds of these women were
single mothers (Little Hoover Commission, 2004). Incarcerated mothers experience high levels of
depression during incarceration, and anxiety related to reunification during reintegration (Morton,
1998). Once released, many incarcerated women have few economic opportunities because they
have limited job skills, education, or support and turn to crime as a means to provide for their
children (Owen, 1995).
The separation of a woman from her children not only affects the mother but has a substantial
impact on her child’s future as well. Children of inmates are five to six times more likely to become
incarcerated than their peers (Bloom, 1993). Ten percent of children with incarcerated mothers are
forced into the foster care system, and 11% experience at least two changes in their care givers
(Dressel, 1998). Often women are sent to prisons far from their homes, making it difficult for
children to visit. In the federal system, only half of the incarcerated mothers receive visits from their
children (Casey, 1996). Furthermore, noisy prison environments detract from the quality of visits.
These stressful and lonely places create lasting negative effects on both the mother and her child.
Another characteristic of women in prison is victimization. While only 16% of male prisoners have
histories of abuse, 57% of female prisoners were physically or sexually abused before their
incarceration (Little Hoover Commission, 2004). The effects of harassment in prison are often
compounded when women have histories of victimization (Amnesty, 1998). Without specific
treatment, issues go untended and often get worse. Hence, the prison system not only neglects to
adequately treat mental health issues but exacerbates them.
Statement of the Problem
The nature of female criminality is different from that of men. Incarcerated women have special
needs including childcare responsibilities, long histories of victimization, and drug abuse—all of
which compromise women’s health when left untreated. As the number of women entering jails and
prisons continues to rise in a dramatic fashion, the need to address their unique circumstances

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becomes increasingly pressing. It has never been more urgent for California to examine its current
system and reform its gender-blind health care policies.

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METHOD
NCCD’s Women and Prison Project
One of NCCD’s main areas of focus is the Women and Justice Initiative, the cornerstone project of
which is The Women and Prison Project: Year One Prisoner Profile. This research is intended to
focus public attention and galvanize political opinion toward meaningful prison reform for women
and girls. Overall, the goals of this project are to reform sentencing laws and correctional practices,
stressing community-based alternatives to incarceration.
NCCD conducted interviews with key stakeholders who have an interest in issues related to
incarceration practices and health care. Stakeholders include representatives from local jails, health
care providers, and community leaders, as well as formerly incarcerated women and their families.
Fifty-one stakeholders were interviewed.
Findings were used to develop a strategy to sustain long-term system change surrounding the health
care of incarcerated women and girls in California. It is NCCD’s intention that these findings serve
as a catalyst for a correctional health care movement for incarcerated women. Currently, policy
makers, the media, and even social activists working on this issue are not well informed about the
facts related to the health care of incarcerated women. Recommendations will be used to facilitate
planning for the specific types of remedies that are needed.
Paper Focus and Research Objectives
The focus of this paper is to present the findings from interviews conducted with key stakeholders
who are involved in issues related to health care and incarceration.
ƒ

Characterize the current system and its provision of health care for incarcerated women in
California.

ƒ

Identify and address gaps in current service provision and the lack of cultural competency in
health intervention programs.

ƒ

Determine the ramifications of current practices in health care delivery to incarcerated women.

ƒ

Outline a strategy to improve quality and access of holistic health care within the system and
during transition back into the community.

Women and Prison Advisory Panel
To help guide our work, NCCD has convened a panel of 14 representatives from San Francisco Bay
Area community-based organizations and correctional institutions, including formerly incarcerated
women. Each panel member is doing tremendous work with women and girls involved in the
criminal justice system. The panel met quarterly to participate in strategy discussions and to provide
a critical eye to the work we produce. Specifically, NCCD wanted to ensure that the planning and
data collection procedures, policy developments, and publications were guided by the panel’s
consensus. Their feedback has been invaluable.

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Sample
To determine the study’s sample, an intensive literature review and internet search was conducted to
identify key stakeholders working in the area of health care and the justice system in California.
Referrals were also collected from NCCD’s Women and Prison Advisory Panel. Key stakeholders
include health care providers working both inside and outside correctional facilities; former
prisoners and their families; attorneys and legal service providers; prison and health care advocates;
religious, adolescent, and substance abuse service providers; policy makers; and other researchers
and academics. Contact and organizational information was collected and stored in a Microsoft
Access database specifically designed for the purposes of this research project. Stakeholders were
selected from the database to participate in an hour-long telephone interview. Project staff mailed a
letter to each stakeholder, which outlined the project and requested their participation in the study.
Then, a follow-up call was made to solicit participation and schedule an interview time. Project staff
interviewed a total of 51 key stakeholders.
Data Collection and Analysis
To gather information specific to this project, NCCD developed the Stakeholder Interview
Instrument (see appendix A). The instrument is open ended and designed to cover a range of broad
topics including stakeholder’s background; physical, mental and reproductive health issues of
women in prison; the quality of health care service delivery and staffing; gaps and barriers to service;
cultural competency and health care rights; and recommendations for improvement and model
programs. The interview instrument was reviewed by NCCD research staff and by NCCD’s Women
and Prison Advisory Panel. Each interview took approximately 60 minutes to complete. Interviews
were taped and later transcribed.
Key themes from 51 completed interviews were extracted and analyzed. Findings are presented.
When necessary, information from the literature review was used to help explain key themes and
supplement findings needed to develop policy recommendations.

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FINDINGS
The institutionalization of sexist, racist, and classist policies affect the fundamental structure of
American society and thus, the current model for corrections, and the incarceration of women in the
United States. These systemic flaws manifest themselves in destructive ways that perpetuate the
status quo: the cycle of violence and incarceration, the criminalization of the mentally ill, the
demonization of prisoners, a pervasive belief in punishment over rehabilitation, and the male centric
model for corrections. These flaws result in the neglect of health care rights of incarcerated women.
A solution to these problems begins with gradual, deliberate movement towards effective and long
lasting systemic change. In keeping with this vision, NCCD seeks to identify specific problems and
viable solutions to improve health care for women in California’s prisons.
In the next sections, NCCD will characterize the current system of heath care provision to
incarcerated women and provide evidence-based recommendations for improvement.
I. PROCESS OF ACCESS TO HEALTH CARE
Stakeholders describe three methods by which an inmate can access health care— the co-pay form,
sick-call, and emergency care. These practices are structured to discourage utilization of services by
creating unnecessary bureaucratic and financial obstacles for prisoners.
Co-pay Form
To schedule a non-emergency appointment, the inmate must fill out a co-pay form. The form
requires a written explanation of patient symptoms and the reason for the request. Medical
personnel collect the forms each morning for review, and after judging the relative importance of
requests, schedule appointments. Women with low literacy levels and poor writing skills have serious
difficulty completing co-pay forms properly. Often, they are unable to communicate the scope or
nature of their symptoms, which increases the risk of potentially dangerous time-delays, and an
incorrect assessment of their condition. In fact, according to stakeholders, appointments are
frequently scheduled several months after inmates submit requests.
Sick-call and Hot Meds
Sick-call is a daily procedure designed to provide an inmate with same-day treatment for pressing
medical issues. The process requires women to go to the medical department, sign in, and wait for
hours outside, regardless of weather conditions, to receive treatment. Thus, sick woman are
subjected to extreme highs and lows in temperature, and pouring rain. Stakeholders also report
women being wheeled to these lines in carts by fellow inmates because they were too ill to stand in
line during the required waiting period. Additionally, sick-call is frequently cancelled. On these days,
women who are ill and require medical documentation excusing them from work are left without
recourse.
A similar policy is in place for women to receive a variety of medications—classified as Hot meds—
they are not allowed to keep in their cells. Women with prescriptions for Hot meds are forced to
stand in long lines two to three times a day, depending on their regimen, to receive their medicine.
In some cases, these women are forced to forgo dinner and other activities while they wait in line.
The structure of the hot meds policy makes it almost impossible to follow the prescribed schedule
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for one’s medication regimen. This can have drastic effects for serious illnesses, such as HIV/AIDS,
that require very complicated and precise drug regimens, which, if not followed, greatly reduce the
efficacy of treatment.
Emergency Care
Emergency care is the only medical treatment available without charge. Prisoners experiencing
medical emergencies, however, are not allowed to contact medical staff directly. Instead, a prisoner
must convince a guard that has little or no medical training, of the seriousness of her condition. The
staff member, in turn, must convince medical staff that the prisoner requires immediate medical
attention. It has been reported that staff members are so convinced of malingering (fabrication of
symptoms) behavior on the part of the imprisoned woman, that they ignore pleas for medical
attention. Such policies of neglect have led to tremendous suffering; several stakeholders recounted
deaths of women whose pleas for medical attention were ignored by prison guards.
Five Dollar Co-pay Charge
Another obstacle to health care is the five dollar co-pay fee that incarcerated women must pay for
each medical visit. Although follow-up care and emergency treatment are theoretically exempt from
the co-pay charge, prisoners often end up paying for these services as well. Five dollars may appear
reasonable according to co-pay policies outside prison, but the extent to which this practice
undermines access to health care is actually quite large. For women with no real financial income
and a host of other expenses, this charge is a heavy monetary burden that functions as a fine for
seeking treatment. Stakeholders indicate that in some cases, women are forced to make the decision
between medical attention and other necessities such as hygiene products. Because inmates don’t
report health problems to avoid co-pay charges, their medical conditions worsen and require more
expensive treatment. Ironically, rather than saving the CDCR money, the co-pay system actually
ends up increasing expenditures (Stoller, 2001).
II. GAPS IN CURRENT SERVICE PROVISION
Mental Health
According to stakeholders interviewed, mental health treatment constitutes the largest gap in health
care service provision for incarcerated women. While the Little Hoover Commission of 2004 cited
almost a third of women in California’s correctional system as having some kind of mental health
problem, stakeholders estimated this figure was actually a great deal higher.
Mental health problems often land women in prison in the first place, and if left untreated, are likely
pull them back behind bars. Prisons function in lieu of mental institutions for many low-income
people. Incarcerated women are often imprisoned for symptomatic deviance, rather than placed in
mental institutions or drug rehabilitation programs to address their underlying illness. Due to the
relationship between mental illness, incarceration, and recidivism, mental health treatment is
especially critical. Stakeholders cite mental health issues as a principle barrier to rehabilitation and
cause of recidivism. Lack of treatment and exacerbation of mental illness within prison walls make
women much more likely to become repeat offenders once they are released.

12

The most common mental health issues affecting women in prison are depression, anxiety, posttraumatic stress disorder (PTSD), and substance abuse. However, interview respondents have
suggested that substance abuse is not a mental health problem in and of itself; rather it is a coping
strategy for dealing with underlying issues of abuse and poverty.
Incarceration can exacerbate and even cause mental health problems. There is an inherent
contradiction between mental health and the punitive nature of prison. Conditions undermining
mental health include isolation, separation from family and children, loss of personal freedom, loss
of sexual outlets, an atmosphere of punishment that decreases self-value, and psychological,
physical, and sexual abuse. Separation from children, in particular, was cited by respondents as one
of the greatest traumas to women prisoners, and a leading factor in their depression. Abusive
conditions within prison walls are especially harmful for the countless women with PTSD, who have
been previously victimized. Perhaps the single most damaging practice for mentally ill women,
whose symptoms are often labeled as illicit behavior, is their inappropriate isolation in Security
Housing Units (SHU). These cells employ mental torture as a means of punishment.

Treatment

Addressing mental health is also critical because of the ways in which mental health problems
inform other physical health issues. Mental attitudes and emotional well being are often critical
components of prevention and treatment for physical illnesses. Additionally, women experiencing
mental illness are more likely to engage in unsafe practices that jeopardize their reproductive health.
Stakeholders believe that prison staff dismiss the significance and repercussions of mental health
issues among prisoners. This disregard leads to grossly inadequate services. Counseling and
intervention programs that address drug addiction are severely limited, such that only a small portion
of the overwhelming population of substance abusers receives services. Preventative care is similarly
scarce, illuminating a policy of reactive measures that address only acute symptoms without targeting
underlying causes of poor mental health.
One of the most obvious ways in which the underpinnings of mental illness are ignored is the
manner in which medication is prescribed as a substitute for mental health treatment. Some facilities
do not have mental health counselors, only psychiatrists prescribing drugs. As a result, many
prisoners receive only medications and no therapeutic interventions. Respondents also mentioned
medical sedation as a method of controlling prison populations.
The lack of confidentiality and mandatory reporting policies governing mental health staff
contribute to an atmosphere of mistrust among prisoners, and can seriously inhibit the efficacy of
mental health treatment. Similarly, prisoners fearing punitive repercussions find it difficult to reveal
their personal histories and speak truthfully to counselors with correctional affiliations.
Reproductive Health
Incarcerated women are especially at risk for reproductive health problems due to histories of sexual
abuse, high rates of sex work, and prior limited access to health care services and education.
Unfortunately, reproductive health services within California’s female prisons are severely deficient,
and reveal significant gender bias generated by a male model of correctional health care.

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There is no systematic or routine administration of mammograms, pap smears, or comprehensive
STD screening. Chlamydia has become a significant problem among incarcerated females,
particularly youth, who experience the highest rates of infection. Chlamydia is a particularly insidious
disease that is often asymptomatic, but can lead to infertility when left untreated.
Despite the fact that routine pap smears assist early detection and treatment of cervical cancer, they
are not routinely administered. When requested, the waiting period can exceed six months. Given
the personal and invasive nature of this procedure, the behavior of staff is critical in establishing
comfort levels for patients. Yet women in California’s prisons are not afforded their legal right to
request attention by female staff, and respondents report that treatment by a largely male staff is
rough and abusive, with instances of using an over-sized speculum, and performing exams in abrupt,
forceful manners. Further, upon completion, abnormal test results are often ignored, and woman are
denied both notification and necessary follow-up care.
Stakeholders also report horrible prenatal care. Some pregnant women, of whom many are
considered high risk, do not see obstetricians nor do they receive sonograms. Concerns such as high
blood pressure, lack of fetal heartbeat, and vaginal bleeding are often ignored, despite the
relationship of these conditions to late-term miscarriage, premature delivery, still birth, and severe
health problems for infants. Pregnant women are shackled for transport to outside hospitals; some
remain shackled during delivery, violating international human rights standards. Adoption agencies
then surface, offering women small financial gifts and other verbal manipulations in exchange for
their babies. These women, who have just endured the trauma of childbirth and may be unable to
make informed, coherent decisions, are coerced into giving up their children. The separation of a
mother from her child can cause serious mental trauma to both the mother and infant, as well as
serious physical repercussions for the child.
The lack of reproductive health care is indicative of a larger disregard for the reproductive status of
incarcerated women, and translates into one of the cruelest forms of medical neglect. One
stakeholder reported that invasive gynecological procedures are conducted without full consent or
knowledge of the women, sometimes resulting in forced or coerced sterilization.
Physical Health

Chronic Illness

Common chronic illnesses of incarcerated women include asthma, heart disease, high blood
pressure, insulin-dependent diabetes, epilepsy, and various forms of cancer. Current health care
services are inadequate and fail to address these and other serious illnesses.

Infectious Disease

Hepatitis C, HIV/AIDS, staphylococcus infections, and sexually transmitted diseases were cited by
stakeholders as the most prevalent infectious diseases. Although tuberculosis is commonly
understood as a problem in prison populations, as was mentioned by some stakeholders, the
majority of stakeholders reported that tuberculosis is no longer a serious concern because outbreaks
are rapid and place prison staff at risk, and are therefore prevented. Consequently, tuberculosis is the
only infectious disease for which a solid testing protocol is in place.

14

Treatment

The discrepancy between treatment protocols for tuberculosis and the remaining infectious diseases
is vast. Characteristics such as drug use, number of sex partners, condom use, and age of sexual
onset, put incarcerated women at risk for many diseases before they even enter prison. Their risk
amplifies significantly when compounded with the poor sanitation and overcrowding of correctional
facilities.
Hepatitis C, in particular, has alarmingly high rates of incidence in prison. Nevertheless, there are no
system-wide prevention, treatment, or counseling protocols in place. Respondents report numerous
instances of women being tested, but not informed of their positive status. Even when notified, the
lack of treatment mitigates the benefits of knowing about the status. Rather, women are ostracized
by staff and inmates alike, as the lack of confidentiality of test results exposes them to this stigma.
Prisoners affected with HIV and Hepatitis C are further disadvantaged because they cannot access
newer, experimental treatments that are widely used in community settings, and are generally more
effective.
Staphylococcus infections are easily transmitted through unsanitary conditions, and increase in
frequency after surgery, due to poor follow-up care. Staphylococcus infections can be fatal.

Medications

A critical component of treatment is medication. Unfortunately, stakeholders cite one of the most
frequent complaints among women prisoners is a delay in receiving their medication. In fact, women
with medical problems that require daily medication, such as heart disease, high blood pressure, and
asthma, often experience delays for days at a time. Women with Hepatitis C and HIV have precise
medication regimens; disruptions are incredibly hazardous and can significantly shorten lives. In
addition, pain medication is notoriously difficult to obtain, even for women recovering from surgery
or suffering from a terminal illness. When a person in such extreme pain is granted palliative
medication, they are required to endure the Hot meds process.

Dental and Vision Services

Gaps in health care include vision and dental services. Eye care is rare, as many incarcerated women
cannot afford exams or eyewear. Dental health is a particular problem, especially for women who
have experienced a lifetime of dental neglect and suffer from methamphetamine and other drug
addictions that cause significant dental problems. Cleanings are rarely administered, and root canals
and other basic dental procedures are not offered. Instead, tooth extraction is the main form of
treatment. Waiting periods to receive dentures and other needed care are sometimes up to a year,
forcing women to endure great pain.
III. CONTINUITY OF HEALTH CARE
Chronic diseases, particularly cancer, have a profound effect on the physical health of incarcerated
women. These negative effects are exacerbated due to the lack of continuity of care in California’s
facilities. Specifically, this lack refers to the inadequate and inefficient medical care provided to
women at every stage of health care service.

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Preventive Care
Prevention efforts allocate resources most efficiently, and promote the highest levels of physical and
mental well being. Women’s prisons employ virtually no prevention services, despite their known
benefit.

Nutrition and Exercise

Stakeholders report inadequate nutrition levels in prison food, as well as limited options for physical
activity. Heart disease, high blood pressure, and diabetes—all diseases that affect imprisoned women
at high rates—frequently develop as a result of poor nutrition and exercise. Given the increasing
numbers of women serving longer sentences, the effects of poor nutrition and exercise are also
rising.

Routine Screening

Because of physiological differences, women require far more routine screening processes than men
to maintain good health. Yet preventive procedures within women’s prisons are limited, only
available upon an inmate’s request, and generally involve waiting periods of at least several months.
Stakeholders report waiting periods of almost a year for procedures, such as the pap smear, that are
supposed to be administered every six months. Cancer, particularly reproductive cancer, often goes
undiagnosed and untreated until the imprisoned woman is in a very serious condition beyond
assistance. Respondents attribute a high proportion of health related-deaths among women
prisoners to cervical cancer.

Education

Compounding the problem is the reality that incarcerated women do not request routine screening
procedures because they lack the health education to know to do so. They have little chance of
learning this information in prison.
Follow-up Care
There are numerous gaps in the provision of follow-up care. Abnormal test results, including pap
smears, are often either completely ignored or addressed after time delays that have already caused
irreparable damage to the woman’s health. It is not uncommon for test results to be misfiled, so that
neither the inmate nor the doctor, know the results. Even in instances where women have selfreferred with breast lumps or discharge and abnormal bleeding, they have waited months before
receiving further testing and care.
Doctors also frequently ignore the recommendations of the previous doctor for follow-up tests and
treatment, particularly if the first doctor is from an outside agency. The lack of individual
accountability is also a problem, as no specific staff member assumes responsibility for ensuring the
completion of the doctor’s recommendations. An inmate might not receive a prescribed wheelchair,
for example, because no specific staff member is accountable for ensuring that the wheelchair was
ordered and delivered. The lack of responsibility is also evident in the careless post-operative
attention female prisoners receive. Prisoners are often neglected after surgery, with bandages left
unchanged and “call bells” unanswered.

16

Transitional Care
The poor follow-up care received in correctional facilities parallels the lack of transitional care
provided for women released from prison. The process of transition out of prison offers no
continuity of care for incarcerated women. Once released, women are not directed to community
resources that will allow them to access health care. Furthermore, these women are generally
unequipped to navigate the bureaucracy of health care outside, and are flooded with a host of other
life management concerns. They face the challenges of finding housing or jobs, and reunifying with
their children. Additionally, few women receive substance abuse treatment upon release. Available
substance abuse programs for released women can treat only a small portion of the women who
actually need drug addiction treatment. Without adequate transitional services to address those
needs, health care is of relatively low concern.
A woman released from prison is abruptly disconnected from even those meager services.
Immediately upon release, women are taken off their medications, are no longer allowed access to
their medical histories, and do not receive notification of abnormal test results that surface even a
day after their release.
Communication between Staff and Institutions
The lack of connection and communication between institutions and among staff causes
fundamental barriers to proper continuity of care. According to stakeholders, medical records are
often not transferred or are lost entirely when an incarcerated woman moves from one facility to
another. Accordingly, prescriptions are also generally discontinued upon transfer between
institutions. Women must also be re-diagnosed for diseases and receive new treatment plans, all
processes that waste resources and lead to delays during which the woman’s illness may worsen.
Procedures that should have been completed during follow-up care must be completed once again
during initial visits, forcing women to waste time and pay additional co-pay fees.
Generally, employees fail to communicate effectively. Nurses and doctors rarely make functional
notes for one another in patient files, leading to poor documentation of patient histories, which can
seriously impede quality of follow-up care.
IV. QUALITY OF STAFF
Some medical employees within corrections facilities are altruistic and hard working. It is crucial that
these employees be supported and provided incentives to maintain their services. However,
interviews revealed that the majority of medical staff in women’s correctional facilities are
inadequate, unqualified, and underpaid. Since employees essentially work as gatekeepers of health
care services, low-quality staff translates into low-quality health care provision.
Positions
Although the number of staff and positions vary among facilities, the basic structure remains the
same, with positions in administrative supervision occupied by the Chief Medical Officer (CMO)
and Health Care Services Manager. Medical Technician Assistants (MTA), nurses, technicians, and
doctors provide the actual medical care. The practices of MTAs were frequently reported as
detrimental to quality care.
17

MTAs illustrate most clearly the incompatibility between correctional and medical duties. They are
essentially custodial staff with less than twenty hours of medical training that they acquire to increase
their salary as correctional officers. As members of the guard’s union, they wear their custodial
uniforms over their medical ones to assert their allegiance. Despite their lack of qualification, they
perform triage, determining whether or not a prisoner requires medical care. Due to their
overwhelmingly negative attitude towards prisoners, MTAs often assume women are malingering or
complaining unnecessarily. Stakeholders have cited numerous occasions of critically ill women who
have been refused treatment by MTAs, with several deaths resulting from these incidents.
Distribution of Resources
Correctional facilities are often viewed as necessary components of society. As such, they are heavily
funded. However, when it comes to adequate health care provision to incarcerated women, the ways
in which correctional facilities distribute their resources is inherently ineffective. A striking example
of an insensible practice involves salary: correctional officers without medical training are often paid
more than prison doctors, as are guards with limited medical training.
Attitudes
Many medical staff exhibit hostile behavior toward incarcerated women seeking health care.
Hostility inhibits appropriate patient-doctor relationships and permeates all aspects of physical,
reproductive, and mental health care. One striking example involves a sign hung in a clinic, which
mandates that patients complain about no more than two symptoms. Creating such an abusive and
suspicious environment further discourages utilization of health care services. All of these practices
undermine the coherence and purpose of the medical program, and encourage an environment
within which it is virtually impossible to either provide or receive effective health care. Moreover,
respondents reported cases of sexual, physical, and psychological abuse of women who are likely to
have been previously victimized.
Qualifications
Respondents frequently indicated that the majority of medical employees in women’s prisons are
under-qualified or lack medical competence. According to a stakeholder, a University of California
study found that 25% of prison doctors were incompetent. Another 50% required extensive reeducation in order to attain competency. The fact that doctors with revoked licenses are only able to
practice in prisons echoes the study’s findings. Many medical employees servicing incarcerated
women would be legally restricted in providing the same services within communities, precisely
because those services would lack in quality.
Administrative Limitations
Women’s correctional facilities are large, crowded, and plagued with administrative barriers. The
health care delivery systems within these facilities are no exception. Often, vital medical information
is excluded from patients’ files, even though documentation is required. One particular issue raised
in interviews was the inconsistency in note-taking within files. This practice impairs the ability of
doctors and nurses to track medical histories. Furthermore, lockdowns and other security measures
are detrimental to staff’s ability to provide comprehensive care.
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V. CULTURAL COMPETENCY
The majority of stakeholders agree that disproportionate minority confinement is a serious issue in
women’s prison facilities. They estimate that over 70% of incarcerated women are minorities.
Therefore, cultural competency, which refers to respect for and understanding of cultures outside of
one’s own, is a serious concern in improving standards of health care for incarcerated women.
Language Barriers
Cultural insensitivity inevitably worsens language and communication barriers. Many incarcerated
women are not proficient in English, and inadequate translation services seriously undermines the
quality of health care these women receive. For example, lack of translated co-pay and 602 appeals
forms may discourage non-English speaking women from seeking medical assistance. It also
eliminates recourse for non-English speakers who wish to protest improper or abusive treatment.
Additionally, medical staff, including primary doctors, are often unable to communicate with women
in their first languages. This situation jeopardizes the well being of these women who may not be
able to effectively communicate their medical problems or understand feedback from staff.
Furthermore, medical staff often use the “proper” form of English indicative of higher socioeconomic status and higher levels of formal education. Many prisoners have never acquired
proficiency in this form of English and may be unable or uncomfortable communicating effectively
with medical staff. Different cultures exhibit different forms of literacy and communication, which
place them at a disadvantage in the written and verbal expression of their illness.
Racial and Ethnic Breakdown of Staff
The world views and beliefs of racial and ethnic groups impact the way in which they understand
illness, express symptoms, view mainstream knowledge and respond to dominant health care
modalities. Yet medical staff within correctional facilities are not representative of the ethnic
distribution of the female prison population. This cultural gap between provider and receiver of
health care services creates serious barriers to adequate health care. Many stakeholders reported the
existence of racist attitudes and discriminatory practices among medical staff towards prisoners of
different ethnic and racial backgrounds. Several interviews suggest that medical staff, who do not
identify with women of color, view these women as dishonest, dirty, unintelligent, and generally
undeserving of adequate health care. Furthermore, reports reveal preferential treatment of
imprisoned white, middle-class women. In addition, given the historically abusive relationship
racialized minorities have experienced with the medical community, stakeholders suggest a general
distrust of health care providers by communities of color. All of these factors translate into the
inability of incarcerated women of color to create an environment that fosters the trust,
communication, and comfort critical to quality health care service.

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RECOMMENDATIONS AND DISCUSSION
Based on these preliminary findings, the stakeholders’ strategies for improvement to health care to
incarcerated women in California are outlined below. Respondents overwhelmingly reported that the
first step toward effective health care provision is the state-wide decarceration of women who do
not belong in correctional facilities. Respondents also suggested strategies to improve services within
correctional facilities, increase continuity of care, and promote cultural competency.
I. DECARCERATE AND PROMOTE ALTERNATIVES TO INCARCERATION
Special Populations
Women’s prison facilities are currently unnecessarily crowded, making the provision of
comprehensive health care difficult and costly. A large proportion of incarcerated women are lowlevel offenders, mothers, disabled, elderly, or chronically ill. In addition, many women undergoing
sentencing and at risk for incarceration share these same circumstances. For these populations of
women, decarceration and the promotion of alternatives to incarceration are the best endorsements
of health and rehabilitation.
Low-level offenders—Low-level offenders include women who have been incarcerated due to nonviolent drug and property offenses, a large proportion of whom have mental illnesses or substance
abuse problems. These women do not pose threats to public safety, and would greatly benefit from
interventions in community settings, including substance abuse treatment, counseling, and financial
advising. Decriminalization of substance addicted and mentally ill women is a necessary step toward
fair and adequate health care provision.
Mothers—It is estimated that over half of incarcerated or at-risk women are mothers to children
under the age of eighteen (Little Hoover Commission, 2004). Moreover, they are often single
parents and are solely responsible for providing parental guidance and care. While in prison limited
contact with their children causes mothers extreme stress. Additionally, the children of incarcerated
women suffer unimaginable anxiety as a result of prolonged separation from their mothers. They are
also far more likely than other children to become involved in the juvenile justice system. It is
imperative to consider incarceration alternatives for mothers, and place them back into the
community where they will be able to receive quality interventions and simultaneously provide
adequate parental supervision and support.
Compassionate release candidates— Hospice units within California’s prisons exist in name only. In
practice, they amount to dismal, solitary rooms where women behind bars wait to die. They do so
without health care services that might prolong their lives and increase their comfort. Inmate
eligibility for compassionate release- a legal procedure that allows a terminally ill prisoner to be
released on parole for the remaining days of her life- needs to be evaluated and applied more
liberally. Not only do many women denied compassionate release pose little risk to public safety,
their release would save the state considerable expense by placing these women in locations
appropriate to the level of care they require. Denying these women some comfort in their last
moments of great suffering is inhumane and purposeless.

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Legislative Reform
Legislative reform is crucial to achieving viable, long-lasting systemic change regarding the
unwarranted incarceration of women. Particularly discriminatory legislation includes the three strikes
laws, mandatory minimums, truth-in-sentencing, and parole revocation policies. These legislative
policies ostensibly diminish subjective practices, but in practice, their greatest consequence has been
the imprisonment of low-level offending women struggling with drug addiction, abuse, and poverty.
II. IMPROVE SERVICES INSIDE CORRECTIONAL FACILITIES
Improve Standards in Health Care Services Quality
Women’s correctional facilities do not provide adequate health care, as necessary services are lacking
in both availability and quality. This failure compromises the physical, mental, and reproductive
health of incarcerated women. The following improvements in the standards of health care
provision is essential to the well-being of women in California’s prisons.
Improve Access to Care— The state should eliminate unnecessary bureaucratic and financial barriers to
care. Eliminating the co-pay fee will increase early utilization of medical services by sick women and
save the correctional system money. The practices of sick call, co-pay forms, and emergency care
must also be dismantled. Alternatives include a sick call system that visits women in their own
housing units through same day appointments. Measures must also be taken to assist women who
struggle with English literacy in requesting appointments. Emergency care as well should be
accessible to all women who feel they require immediate medical attention. A system that assumes
the women cannot be trusted cannot provide them adequate health care.
Promote protocols and policies that protect incarcerated women—Moreover, protocols and policies that protect
incarcerated women should be created to increase standards of service. Such policies should be
gender-specific and prioritized according to the specific needs of the women they are intended to
serve.
Increase prevention efforts—Prevention efforts should likewise be increased to prevent unnecessary
health complications and painful conditions. Specifically, exercise and nutritional needs must be
addressed, routine screenings should be systematized, and voluntary testing for threatening or
infectious disease must be made available and kept confidential.
Provide quality education—Another important component in the improvement of standards is the
provision of quality health education. Effective education programs would inform women about
prevention and coping strategies with which they may be unfamiliar. Health education is effective in
maintaining health and addressing disease. Peer education in particular has demonstrated efficacy as
well as rehabilitative benefits.
Prioritize mental health—There is no doubt that many incarcerated women have been victimized. The
prioritization of mental health services is therefore crucial to these women’s psychological and
emotional well being. To achieve quality mental health services, the availability and quality of
counseling and assessment must be increased. Specifically, it is crucial that these therapeutic
interventions involve adequate one-on-one interactions with qualified therapists, and do not merely
entail the distribution of medication without counseling. Furthermore, these interactions must
21

remain confidential so that incarcerated women are able to form trusting relationships with health
care providers. In addition, the importance of mental health must be recognized and accepted by the
correctional system and its employees.
Prioritize reproductive status—The promotion of reproductive health is essential to providing effective
gender-specific health care. Prenatal care, fertility protection policies, regular feminine care, and
access to feminine hygiene must be provided to all incarcerated women. Given that a large
proportion of correctional staff are male, issues related to reproductive health may be deemed
irrelevant in prisons, when in fact such issues are crucial to women’s health.
Eliminate Administrative Barriers
Administrative obstacles are inherent to large institutions, and reduce efficiency. Deliberate steps
must be taken to correct for such administrative barriers, especially when repercussions jeopardize
the lives of inmates.
Transfer the provision of health care services to an agency outside of CDC jurisdiction— A system structured
around punishment is fundamentally unable to provide adequate health care to women in prison.
Utilizing an agency outside of CDC jurisdiction such as the Public Health Department/Department
of Health Services, the UC Medical School system, or other non-profit organizations was most
frequently cited by stakeholders as the most important step in reforming health care service
provision to incarcerated women. Such a move eliminates problems of dual loyalty and
confidentiality for medical staff, ensuring that medical rather than correctional standards govern the
provision of health care services. Having community providers result in community standards of
care, and establish links with community agencies that facilitate smoother transitions for women
upon release.
Improve standards and responses—Standards for record keeping should be increased to improve the
reliability and validity of patient health care information. Responses to abnormal test results must be
systematized in order to prevent serious health complications. Also, protocols should be created to
eliminate time delays and facilitate the provision of health care services.
Promote accountability—The accountability of correctional facilities and staff must be enforced in order
to assure that illegal practices are eliminated. Specifically, the roles and responsibilities of staff
should be well defined, and individual staff should be monitored. Additionally, the transparency of
correctional facilities with regards to health care should be increased and public awareness
promoted. Also, the appeals and grievances process should be improved so that patients can help
advocate for the quality of their health care.
Improve Quality of Staff
Oftentimes who determines whether incarcerated women receive health care services are the staff
these women come into contact with on a daily basis. Also, the competency and attitude of staff can
affect the psychological and emotional states of the women they encounter. As such, it is crucial that
staff quality be taken seriously. Specifically, standards of hiring must be improved, and recruitment
and retention incentives provided in order to assure that competent and well-intentioned staff are
employed. Furthermore, quality training must be provided to ensure that the correct services are
administered and positive attitudes are exhibited. Importantly, support should be given to
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competent staff already in place, so that they are retained and used as valuable resources in training
of new staff. Finally, the use of MTAs—who have virtually no medical training—must be
eliminated, as they are not in a position to make meaningful health care assessments for prisoners.
III. SUPPORT CONTINUITY OF CARE
Few female offenders are incarcerated for life, and will inevitably face the challenge of transitioning
back into their communities upon release from prison. Formerly incarcerated women face incredible
difficulties upon release—trouble finding food and shelter, getting a job, paying the bills, and caring
for their children. Health care, therefore, is often a last priority. However, it is incredibly important
to provide adequate transitional health care to ensure the safety and health of formerly incarcerated
women, their families, and the communities to which they return. In reality health problems can
undermine success with all the rest of women’s goals.
Adequate transitional care includes linking incarcerated women with community-based health
organizations prior to their actual release from prison. This practice will also facilitate an equally
important aspect of effective transitional care: efficient transfer of medical records. These policies
will help ensure that incarcerated women’s medical histories are preserved and communicated to
health care providers outside of prison. Also, given that many incarcerated women receive
medication inside of prison, correctional health care providers must ensure the provision of an
adequate supply of medication to women who are released.
In addition, women should be provided education on a range of community resources, and taught
how to make use of these resources. Such resources should not be limited strictly to health care
organizations. Rather, resources should help formerly incarcerated women successfully make the
transition into a healthy and productive life, and can include child care facilities, career and financial
advising, social work organizations, and mental health facilities.
IV. PROMOTE CULTURAL COMPETENCY
It is estimated that almost three quarters of incarcerated women in California identify as ethnic or
racial minorities (Little Hoover Commission, 2004). Given these demographics, California’s
correctional system cannot provide quality health care to imprisoned women without addressing
cultural competency. Steps must be taken to prevent both intentional and indirect discrimination,
which may result from culturally insensitive policies and practices.
Provide translation services—Cultural diversity often means differences in language and communication.
It is imperative that both verbal and written translation services be available to women who struggle
with English. To deny incarcerated women such access effectively reduces their ability to obtain
adequate health care services.
Representative staff and training—Corrections staff must be trained on cultural sensitivity to avoid
discriminatory practices. Furthermore, efforts should be made to hire staff representative of the
ethnic and racial backgrounds of incarcerated women. In this way, an environment of trust and
communication can be fostered. These practices would also reduce language barriers, as staff would
have better communication with the women they supervise.

23

Holistic approach to health care—The current correctional system provides only allopathic, or
“Western,” medical treatment. Some incarcerated women, the majority of whom are minorities, may
be unfamiliar or uncomfortable with allopathic interventions; what seem to be normal practices
from a mainstream perspective may appear harmful and intrusive to women of other cultures.
Therefore, health care services would benefit from the introduction of alternative medical practices
in correctional health care facilities.
CONCLUSION
This paper presents findings based on information gathered from key stakeholders working in areas
involving women, health care, and incarceration. The study characterizes the current system of health
care service delivery to incarcerated women, and provides policy recommendations for improvement.
Given that incarcerated women in California face numerous obstacles in accessing quality health care—
services, continuity of care, and culturally competent practices are all inadequate—stakeholder
recommendations should be implemented to provide a more humane system of health care.

24

REFERENCES
Acoca, L. (1996). The crisis: The women offender sentencing study and alternative sentencing recommendations
project: Women in prison. Oakland, CA: National Council on Crime and Delinquency.
Acoca, L. (1998). Diffusing the time bomb: Understanding and meeting the growing health needs of
incarcerated women in America, Crime and Delinquency, 44 49-69.
Amnesty International (1998). United States of America rights for all, not part of my sentence: Violations of the
human rights of women in custody, Retrieved July 7, 2005, from
http://web.amnesty.org/library/print/ENGAMR510011999.
Bloom, B. (1993). Incarcerated mothers and their children: Maintaining family Ties, Laurel, MD: American
Correctional Association.
Bloom, B., Chesney-Lind, M., and Owen, B. (1994). Women in California prisons: Hidden victims of the
War on Drugs, San Francisco, CA: Center on Juvenile and Criminal Justice.
Bureau of Justice Statistics. (1999). Women offenders,. Washington, DC: US Department of Justice.
Casey, K.A. and Wiatrowski, M.D. (1996). Women offenders and “three strikes and you’re out”. In
D. Shichor and D.K. Sechrest (Eds.) Three strikes and you’re out: vengeance as social policy (pp. 222243). Thousand Oaks, CA: Sage
Dressel, P., Poterfield, J., and Barnhill, S.K. (1998). Women behind bars: Incarcerating increasing
numbers of mothers has serious implications for families and society. Corrections Today, 60:
90-94.
Hall, E. (2001). Women on parole: barriers to success after substance abuse treatment, Retrieved July 6, 2005,
from http://www.findarticles.com/p/articles/mi_200110/ai_n8992177/print.
Little Hoover Commission. (2005). Breaking the barriers for women on parole, Sacramento, California.
Morton, J., and Williams, M. (1998). Mother/child bonding: Incarcerated women struggle to
maintain meaningful relationships with their children. Corrections Today, 60(7): 98-105.
National Institute of Corrections. (2002). Staffing analysis for women’s prisons and special prison Populations,
Logmont, CO: LIS Inc.
Owen, B., and Bloom, B. (1995). Profiling the needs of California’s female prisoners: A needs’ assessment.
Washington, DC: U.S. Department of Justice.
Stoller, N. (2001). Improving access to healthcare for California’s women prisoners, Retrieved July 7,
2005, from http://www.ucop.edu/cprc/stollerpaper.pdf.
The Correctional Association of New York. (2000). Healthcare in New York State prisons: A report
of findings and recommendations by the prison visiting committee, Retrieved July 8, 2005,
from http://www.correctionalassociation.org/publications/healthcare.pdf.
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APPENDIX: INTERVIEW INSTRUMENT
WOMEN AND PRISON STAKEHOLDER INTERVIEWS
[READ] Through this survey, we would like to get your insights on a variety of healthcare-related
issues faced by women in California prisons and jails. The interview is intended to take 30 minutes.
Please feel free to voice any questions or concerns you may have about the content of this survey or
about our project.
[READ.] We’ll start with a few questions about your background and experience with issues faced
by women in the justice system.

Q1.

First, a very general question: What kind of work related to female offenders do you do?

Q2.

For how long have you been working with issues related to women in the justice system?

Q3.

Do you do this work professionally, or as a volunteer?

Q4.

Briefly, what motivates you to engage in this work?

[READ.] Now, I’d like to ask you about health issues facing women in California’s justice system.
Q5.

What are the three most important mental health issues for women in California jails and prisons?

Q6.

Thinking now of infectious diseases, in your opinion, what are the three most urgent threats to the
physical health of women in California jails and prisons?

Q7.

In your opinion, should jails and prisons require testing for infectious diseases for all inmates?
[Interviewer note: Infectious diseases = communicable diseases; e.g. HIV/AIDS, Hepatitis in all
forms but especially Hepatitis C (HCV), and Tuberculosis (TB). Also includes STDs and many
food borne illnesses.]
Q7a.

(Ask if YES) If infectious disease testing were mandatory, what types of health and
mental health services would then be needed?

Q7b.

(Ask if NO) What might be some long-term implications for women in the justice
system if communicable disease testing remains voluntary?

26

Q8.

What are the most important reproductive health issues facing women in prison?

Q9.

What, if any, are other significant health issues facing women in the justice system?

[Read.] In this next section, I’d like to gather your insights about healthcare service delivery to
incarcerated women.

Q10.

Do you feel that women’s jails and prisons have enough quality staff to handle the number and
severity of health issues faced by incarcerated women?
Q10a. (Ask if Q10 = NO.) What recommendations would you make to improve the quality of
medical staff at women’s prisons and jails?

Q11.

Do you feel that prisons and jails offer an appropriate selection of services to meet the healthcare
needs of incarcerated women?
Q11a. (Ask if Q11 = NO) What services are missing?

Q12.

What are the major barriers to healthcare service delivery to incarcerated women?

Q13.

What recommendations would you make to promote culturally-competent health care to women
in the justice system?

Q14.

What would an ideal system of health care service delivery to incarcerated and paroled women
look like?
Q14a. What barriers exist to implementing the system you’ve just described?
Q14b. At a minimum, what should a health care service delivery system for women in prison
and on parole look like?

Q15.

What are the gaps in the continuum of healthcare services for women in the justice system? In
responding, please consider the healthcare system as a whole, in addition to the areas we have
specifically talked about.
Q15a. What factors contribute to each of these gaps?
Q15b. What can be done to close each of these gaps?

27

Q16.

What are the most serious consequences of inadequate healthcare service delivery for the families
and communities of incarcerated and paroled women?

Q17.

What are the most serious consequences of inadequate healthcare service delivery to female
prisoners and parolees for the corrections system?

Q19.

In your opinion, what, if any, are the pros and cons of privatizing healthcare service delivery to
women in prison?

In this last section of the interview, I would like to direct your attention to the future of healthcare
service delivery for incarcerated, jailed and paroled women.

Q20.

In your opinion, what, if any, are the most important positive developments involving healthcare
delivery to incarcerated women?

Q21.

In your opinion, which approaches and mechanisms, if any, are most effective in enforcing
prisoners' rights to adequate health care?

Q22.

What are the three most important improvements you would make in healthcare service delivery
to incarcerated and detained women in California?

Q23.

[READ] I have just one more question for you: As part of this project, we’re looking for model
programs that address the health care needs of women in the justice system. Do you know of
good programs we should look into?

[READ] Thank you again for taking time to talk with me today. We appreciate your sharing your ideas
and opinions with us, and we’ve learned a lot from this conversation. If a question or concern should
come to mind regarding the survey or this study, please don’t hesitate to call us; we’d be happy to talk
with you again.
[TERMINATE]
END OF SURVEY

28