of US Jail and Prison Policies on the Health and Well-Being of
Women of Color
2002, Vol 92, No. 12 | American Journal of Public Health
Nicholas Freudenberg is with
the Program in Urban Public Health, Hunter College, City
University of New York.
Correspondence: Requests for
reprints should be sent to Nicholas Freudenberg, DrPH, Box
609, Hunter College, 425 East 25th St, New York, NY 10010
In the past few decades, US policies have led to an
unprecedented increase in the number of people
behind bars. While more men than women are
incarcerated, the rate of increase for women has
Evidence of the negative impact of incarceration on the
health of women of color suggests strategies to
reduce these adverse effects. Correctional policies
contribute to disparities in health between White
women and women of color, providing a public health
rationale for policy change.
Specific roles for health professionals include becoming
involved in alliances addressing alternatives to
incarceration, creating programs that address the
needs of women in correctional facilities, and
identifying the pathways by which correctional policies damage
NATIONAL DEBATES ON CRIME, race, and incarceration have
usually focused on men rather than women and on
justice and public safety rather than health. Yet,
high rates of incarceration affect the well-being
of women of color directly, in that incarcerated women
are removed from their communities, they are placed in close
proximity to a population of women with high rates of infectious
and chronic diseases, and opportunities to link them to
needed services are missed. Incarceration also affects
families by separating women from their children,
often forcing children into foster care and leaving
them vulnerable to psychological, educational, and
Prison eliminates current income and reduces future
earnings by diminishing women’s prospects for
Moreover, even a short stay in jail can lead to
Equally important and less addressed in the literature,
criminal justice policies aimed at men can also
harm women. The disproportionate incarceration
rates among Black and Latino men affect women by
reducing the pool of male partners who can contribute to family
reducing overall employment rates in low-income communities,
and diminishing men’s ability to be consistent and
For some women, the incarceration of an abusive or
criminally involved partner can offer safety. However, the
vast majority of men return to their homes from jail or prison,
and thus the failure of correctional facilities to provide
most incarcerated men with substance abuse, mental health,
or domestic violence services forces many women to make
an unpalatable choice. They can either separate
from a male partner who returns from jail or
prison, thus reducing financial and emotional support, or
take back a man with drug, violence, or psychological problems
that may jeopardize the family’s health and safety.
Here I review evidence of the impact of current
incarceration policies on the health of women of
color and suggest public health programs, policies,
and research to reduce adverse effects. I also
argue that current correctional policies contribute to health
status disparities between White women and women of color,
providing a public health rationale for policy change.
GROWTH OF THE POPULATION
In the past 2 decades, US criminal justice, drug, and other
social policies have led to an unprecedented increase in
the number and proportion of people behind bars.
These increasing rates of incarceration have had a
disproportionate impact on people of color.
Moreover, although the vast majority of inmates are
male, the proportion of women who are in jails and prisons
has grown at almost twice the proportion of men since
Between 1980 and 1997, the number of women in state and
federal prisons increased nearly sevenfold.
In 1998, there were an estimated 3.2 million
arrests of women, accounting for 22% of all arrests
that year. More than 950 000 women were under correctional
supervision in 1998, about 1% of the US female
In the past decade, the numbers and proportions of women
have increased in terms of all components of the
system: jail, probation, parole, and prison.
Each component has unique influences on health,
but the focus here is on the cumulative impact of the
correctional system as a whole.
CORRECTIONAL FACILITIES AND
WOMEN OF COLOR
The Bureau of Justice Statistics estimates that 11 of every
1000 women in the United States will be incarcerated at
some point in their lives.
Reflecting the disproportionate representation of
women of color in jails and prisons, lifetime risks per 1000
women are 5 for Whites, 15 for Latinas, and 36 for
Blacks. In other words, a Black woman is more than
7 times as likely as a White woman to spend time
Women in the correctional system are typically young, poor,
and of limited formal educational attainment.
The median age of incarcerated women is 35 years;
about 70% of these women are mothers of children
younger than 18 years, and fewer than 40% have a
high school diploma or its equivalent.
Results derived from a national sample showed that
48% of jailed women reported having been physically
or sexually abused before admission, and 27% had
been raped.Studies conducted in urban jails have shown that
rates of recent homelessness among incarcerated women are
as high as 40%.
Women behind bars face an assortment of intersecting health
and social problems. In comparison with other low-income
women, they have higher rates of (1) recent and
chronic substance use problems;
(2) HIV/AIDS, hepatitis C, and other sexually transmitted
and (3) mental health problems.
In some jails and prisons, there are extraordinary
concentrations of women with illnesses. For
example, a study conducted among the New York City
jail population in 1997 revealed that the rate of
early syphilis in women in jail exceeded that year’s rate
among all women in New York City by more than 1000-fold.
Also, a study of the Chicago jail system showed that
more than a third of incarcerated women had been
diagnosed with posttraumatic stress disorder.
In comparison with the overall population of women
residing in the Chicago area, Black and Hispanic women entering
the system were about 10 times more likely to have a
Even though women behind bars have high rates of health and
social problems, few receive help while they are
incarcerated. It is estimated that no more than 10%
of drug-abusing women are offered drug treatment in
jail or prison,
and most jails lack comprehensive discharge
planning or aftercare programs. According to a 1998 national survey, only two fifths of
male and female jail inmates with mental health
problems received any help while incarcerated,
and when help was offered it usually involved
limited services such as 12-step groups. Although health
care is a constitutional right for prisoners, many women behind
bars receive inadequate or incompetent care.
In addition, most women leaving correctional facilities
return to communities that present inadequate
educational, housing, and employment opportunities.
Despite the recent period of national prosperity,
low-income communities of color continue to have
the worst schools, the fewest job opportunities, and the
least affordable housing.
All poor families suffer from these conditions, but
people of color returning from correctional facilities
face the triple jeopardy of poverty, racism, and stigma
The incarceration experience often contributes to a
downward cycle of economic dependence, social
isolation, substance abuse, and other physical and mental
health problems. Because they have more parental
responsibilities than men leaving correctional
facilities, along with lower wages and higher rates
of psychiatric symptoms and victimization in the
form of violence,
women ex-offenders face unique reentry challenges.
Recent policy changes may have unintentionally made
successful community reintegration of inmates even
more difficult. For example, as a consequence of
the Personal Responsibility and Work Opportunity
Reconciliation Act of 1996, help is less readily available
to many women, especially those with substance abuse or
mental health problems. The programs associated with this
act often involve punitive behavioral expectations—for
example, abstinence from substance use as a condition
for receipt of benefits—and women with drug
problems may have troubling meeting such criteria,
especially when high-quality drug treatment is
scarce and few programs address the special needs of women.
Current regulations of the US Department of Housing and
Urban Development require public housing projects
to evict families with whom a convicted felon
resides, forcing some women leaving prison to
abandon their children or partners or become homeless.
Advocates of current criminal justice policies argue that
the most important benefit of these policies has
been the dramatic reduction in crime and violence
in the past decade.
African American and Latino communities have
benefited significantly from these lower rates,
both directly (through reduced numbers of deaths
and injuries) and indirectly (through the contributions of
lower crime rates to improved economic development).
While many experts question whether higher
incarceration rates (rather than national
prosperity) lead to reduced crime rates,
elected officials continue to advocate for more prison
cells and more aggressive policing to further
African American and Latino communities have borne a
disproportionate burden of the adverse effects of
aggressive policing and "zero tolerance"
Moreover, as a result of prison expansion, correctional
budgets in many states now equal or exceed those for
education and health care.
This shift of resources has a disproportionate
adverse effect on communities of color, which rely
on publicly funded health care and education, and on women,
who are often responsible for managing family health and
CAN INTERVENTIONS MAKE A
While women of color returning home from correctional
facilities face daunting challenges, a significant
body of evidence describes promising approaches to
reducing drug use, HIV risk, and rearrest and
promoting links to health and social services and successful
A few examples illustrate some of these models. In
Hampden County, Massachusetts, for instance, a
partnership between a health department and a county jail
offers coordinated jail and community health and social services,
assistance in obtaining Medicaid benefits, and ongoing postrelease
case management and primary health care services.
A program aimed toward women leaving Bedford Hills
prison in New York State offers educational
opportunities and HIV prevention, health education,
and postrelease counseling services.
Health Link, a program for women leaving New York City
jails, provides health education, social support,
and case management during incarceration as well as
a year of postrelease services to help women reduce
their drug use, HIV risk behavior, and risk of
These brief examples, and a number of recent reviews,
illustrate that it is possible to address the health and
social needs of incarcerated women and to reduce
the adverse health consequences of incarceration.
Common characteristics of such interventions
include the following: prerelease as well as postrelease services;
integration of drug treatment, health care, employment and
vocational training, social services, mental health, and housing;
activities conducted at the client, community, and policy
levels; and strong partnerships among correctional and public
health agencies and community organizations.
Unfortunately, few women leaving jail/prison have
actually received services that can be expected to
make a difference.
CORRECTIONAL POLICIES AND
DISPARITIES IN HEALTH
The growing interest in racial and gender disparities in
health promises new insights into the causes of
these differences and their possible solutions. Too
often, however, researchers have focused on the
specific causes of a particular disparity in health
conditions, thus losing sight of the more fundamental causes
underlying disparities in multiple conditions.
An alternative approach would be to consider the
social processes that underlie multiple disparities
and then develop programmatic and policy interventions
designed to reverse or mitigate the adverse effects of
Social processes are defined here as the dynamic
historical forces that move people to different positions
within the social structure. The high incarceration
rates of women of color, and the failure to focus
on their reintegration after release, represent one
Correctional policies can contribute to adverse health
outcomes through various pathways. Incarceration
itself can increase the risk of infection, sexual
assault, and improper medical care or contribute to
posttraumatic stress disorder.
Reduced income as a result of incarceration-related job
loss or employment discrimination compromises a
woman’s ability to provide adequate housing,
nutrition, and health care for her family.
Stigmatization of returning offenders can lead to social
isolation, which has been linked to various physical and
At the community level, evidence suggests that flooding
low-income urban communities with ex-offenders
without providing adequate aftercare services can
lead to community disruption and higher crime
rates, damaging social cohesion and its healthenhancing effects.
More broadly, the racial dimensions of current criminal justice
policies contribute to the growing racial/ethnic and income
inequalities in the United States, inequalities that have
been associated with poor health outcomes.
The gendered character of these policies reinforces
women’s lower socioeconomic status and fails to
address gender-specific needs related to violence,
reproduction, and mental health.
If incarceration policies exacerbate health disparities,
the Healthy People 2010 goal of eliminating
provides public health professionals with a clear
rationale for research, practice, and advocacy in
the area of alternative programs and policies.
Because the health effects of incarceration operate
through multiple pathways, no single strategy will reverse
these adverse effects. Table 1
summarizes some of the potential goals for policy
changes designed to improve the well-being of
people involved in the correctional system; all of these changes
will benefit both men and women, although each has
gender-specific dimensions. Some address
"upstream" determinants (e.g., reducing the
number of people who enter prison by improving economic opportunities
and access to drug treatment); others seek to reduce
rearrest rates by emphasizing rehabilitation rather than punishment
TABLE 1 —Policy Goals Aimed at Reducing the
Adverse Health Effects of Incarceration
Health, Public Safety, and Economic Outcomes
alternatives to incarceration
family and community disruption; fewer foster care
placements; reductions in drug use; lower
quality of health, mental health, and substance
abuse services in correctional facilities and
develop gender-specific programs
identification and treatment of infectious
diseases; higher levels of adherence to prescribed
medications, leading to less drug resistance;
lower rates of postrelease transmission; improved
readiness for postrelease drug treatment; lower
rates of recidivism
discharge planning and linkages with community
access to health care postrelease; improved
control and management of infectious and chronic
diseases; lower rates of recidivism
and improve vocational and employment programs for
inmates and ex-offenders
capacity for postrelease employment and less
dependency; higher postrelease legal income;
reduced involvement in drug trade
stigmatization of ex-offenders
social isolation; improved community
reintegration; improved social cohesion.
Achieving the policy changes listed in Table 1
will require public health workers to join or
create new alliances. For example, the growing
international interest in the links between health and
human rights may provide a forum for discussion and action.
In recent years, both Amnesty International
and Human Rights Watch
have issued reports documenting the abuse of women in US
prisons and called on this country to abide by international
standards regarding the treatment of this vulnerable
population. The women’s movement is another
possible partner, especially in terms of its focus
on the special needs of women of color.
A recent US Supreme Court decision that banned South
Carolina from incarcerating pregnant drug-using
women on the basis of a positive drug test
illustrates the potential for linking public health,
feminist, and social justice issues.
The increasingly vocal critics of the war on drugs are also
possible allies. The dissatisfaction with the results of
this war, the high costs of incarceration, and the
renewed interest in harm reduction approaches to
may help in efforts to gain public and political
support for policy changes. Recent reports on the
specific impact of the war on drugs on women
suggest areas for collective action.
In the past 5 years, the prisoners’ rights
movement has also grown in strength and
sophistication. Its grass roots campaigns aimed at
halting prison construction, encouraging dialogue on incarceration
policies, and eliminating capital punishment
have created opportunities for public education and
Finally, in a potentially important reversal of earlier
trends, it appears that local and state political
officials may be open to new approaches. For the
first time in almost a quarter century, incarceration
rates have stabilized or declined in the past 2
creating opportunities for reconfiguration of services. Because
the costs of incarceration have increased over the past decade,
and because public revenues targeted toward state governments
are now declining, some public officials are looking for
new, more effective and economical correctional
policies and better links with public health
What role can public health professionals play in changing
criminal justice policies and reducing their
adverse health impact on women? First, we can
develop partnerships with correctional agencies and
community service providers to strengthen health and
social services in jails and prisons and to create community
reintegration services that link women to needed
services and ease the transition into the
"free world." Programs that meet the
specific needs of returning female inmates with regard to
housing, substance use, mental health, reproductive
health, parenting, and employment are especially
Other urgent needs are for systematic evaluation of the
many small programs that seem promising and for
additional attention to the issue of bringing
successful models to scale.
On the research front, investigators need to understand
better the specific pathways by which various
aspects of correctional policy or practice
contribute to adverse health outcomes. For example,
do women leaving prison with untreated posttraumatic stress
disorder fare worse than other released women? Does
participation in correctional literacy or college
programs reduce postrelease health problems? Do
women returning to communities with high proportions
of ex-offenders have higher rates of recidivism or
illness than those returning to low-prevalence areas? The
goal of such research would be to identify opportunities
Eliminating the health disparities that burden women of color
in the United States has been identified as a national
health goal for the next decade,
providing the public health community with a
mandate to join the effort to change criminal justice policies.
However, achieving this objective will require more than
documenting disparities or analyzing their causes. It will
necessitate ongoing action to modify the social
processes that so consistently produce these
differential health outcomes. Current incarceration
policies represent one such process. By working
with public officials, correctional agencies, women’s rights
and criminal justice advocacy groups, and citizens to change
health-damaging correctional policies, public health professionals
can help to improve the health and well-being of
women of color and their families and communities, protect
public safety, and promote social justice.
This work was supported by the Robert Wood Johnson Foundation
and the New York City and New York State health
The comments of Beth E. Richie, Wendy Chavkin, Bea Krauss,
and 3 anonymous reviewers are gratefully
The views expressed herein are those of the author and do
not necessarily represent those of the funding
Accepted for publication August 21, 2002.
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