From Crisis to Care-Ending the Health Harm of Women's Prison-Feb. 2023
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February 2023 EXECUTIVE SUMMARY This report aims to center the experiences of people incarcerated in California women’s prisons, which remain a serious and entrenched public health crisis. According to data from the California Department of Corrections and Rehabilitation (CDCR), in 2022, there were 3,699 people incarcerated in women’s prisons in California. Due to the way that racism and transphobia permeate the criminal legal system, from policing to the courts to incarceration and beyond, Black people and transgender people are more severely criminalized and experience a disproportionately higher rate of incarceration. In 2022, 25% of people in prison in California were Black, even though Black people make up only 6.5% of the California population. According to a survey administered by CDCR, almost 2,000 transgender people are incarcerated in California prisons. This report — informed by public health research alongside interviews and survey responses from people currently and formerly incarcerated in women’s prisons — exposes the catastrophic health harms of incarceration in women’s prisons and provides evidence in support of investments in health-promoting social determinants of health instead of incarceration. The criminalization of trauma and gender identity are major drivers of incarceration. Research shows that 77% to 90% of people incarcerated in women’s prisons report having experienced prior emotional, physical, and/or sexual abuse. A disproportionate percentage of transgender people also report significant trauma prior to incarceration, including experiences of bullying, family rejection and isolation, eviction, criminalization, and mistreatment by police. Each of these factors is associated with higher rates of incarceration, primarily due to a lack of investment in community-based mental health support services and non-carceral violence intervention. People incarcerated in women’s prisons often already have poor health and neglected healthcare needs when they enter prison, due to prior trauma and abuse and lack of access to community healthcare services. Incarceration leads to even worse outcomes, via multiple pathways: 1. Medical neglect — including failure to provide medical examinations, stopping needed prescriptions, and long delays in treatment — is common in prison. People in women’s prisons have faced particular medical abuse related to HumanImpact.org/HealthNotWomensPrisons 1 reproductive health, including lack of prenatal care, coerced sterilization, or untreated reproductive health issues. For transgender people, gender-affirming care is infrequently provided, leading to harmful consequences such as depression, self-injury, and suicide. 2. Alongside the violence of the criminal legal system itself, people incarcerated in women’s prisons also experience and witness high rates of interpersonal physical, emotional, and sexual trauma and violence, which is harmful to both physical and mental health. People incarcerated in women’s prisons face particular violence within the system. In our survey, 47% of respondents experienced sexual and/or gender-based violence while imprisoned. 3. Environmental conditions in prisons seriously endanger the health of incarcerated people, by exposing them to infectious disease, extreme heat and cold, inadequate food, foodborne illness, mold, toxic drinking water, and more. 4. Despite the United Nations Special Rapporteur stating that the use of solitary confinement amounts to torture, solitary confinement is often used in women’s prisons, particularly for transgender people. The use of solitary confinement can lead to increased psychological distress, anxiety, depression, PTSD, paranoia, agitation, sleep deprivation, and prescription of sedative medications. It can also lead to physical ailments like bed sores, weight loss, rashes, dry skin, fungal growth, and hypertension. 5. Separating people from their families and communities has destructive consequences. Over 60% of people incarcerated in women’s prisons are mothers of children under the age of 18. Separation from parents, including via the family policing system, is linked to attention difficulties, aggression, and negativity in children. Incarcerated LGBTQI+ people are at high risk of losing material, emotional, and social support after imprisonment, which has real impacts on health. The economic instability families face when they lose a source of income can lead to a range of consequences, including difficulty meeting basic housing needs, maternal depressive symptoms, and worse health for caregivers and children. The state of California invests $405 million a year in its women’s prisons. Instead of perpetuating a system that overwhelmingly works against public health , the state has the opportunity to invest that money in health-promoting support systems that people can access in their own communities. These public safety investments HumanImpact.org/HealthNotWomensPrisons 2 would not only support reentry after incarceration, they would also help to prevent harm from occurring in the first place, creating the conditions that would make women’s prisons obsolete. This report provides public health evidence for investment in: 1. Safe, stable, and affordable housing: People formerly incarcerated in women’s prisons experience houselessness at 1.4 times the rate of people formerly incarcerated in men’s prisons. Being unhoused can lead to re-incarceration because of the criminalization of houselessness (e.g., sleeping in public places), thus contributing to the vicious cycle of the criminal legal system. Governments should prioritize investments in housing and the supportive programs that people need to stay housed. An evaluation of a supportive housing program for those who had previously cycled in and out of jails in New York City found that, after one year, 91% of those who participated in the program were in permanent housing, compared to 28% of those who did not participate. It is also essential to remove discriminatory practices and policies that prevent people with a record of prior incarceration from accessing housing. 2. Increased employment opportunities: The unemployment rate for formerly incarcerated people — around 27% — is nearly 5 times higher than that of the general population, and higher than the overall US unemployment rate at any point in history. Creating employment opportunities for formerly incarcerated people benefits both the employer and the employee. For the employer, research has found that employees with a record of incarceration are less likely to quit and more likely to stay on staff for longer periods. For formerly incarcerated people, employment is a pathway into health via economic security, housing stability, adequate nutrition, and accessible healthcare. 3. Affordable health care: Formerly incarcerated cisgender women and TGI people, who often carry extensive histories of emotional, physical, and sexual trauma and violence prior to and during incarceration, have disproportionately high rates of health needs. Investments in community-based, supportive mental healthcare, substance use treatment, and physical healthcare are necessary to keep communities safe and healthy. At the policy level, drug decriminalization and Medicaid expansion for incarcerated people prior to their release from prison will be most effective at improving health outcomes. HumanImpact.org/HealthNotWomensPrisons 3 4. Accessible and reliable transportation: For those going through reentry, an accessible and reliable form of transportation is necessary to access healthcare and support services, mobilize in case of emergency, connect with families and loved ones, and maintain stable employment. However, research finds that many people returning from women’s prisons do not have access to a personal vehicle. Public transportation can be unreliable, unsafe, inaccessible, or inconvenient. Investment in reliable transportation removes barriers to health care, employment, and parole or probation appointments, reducing the risk of reconviction. 5. Non-carceral, non-punitive forms of accountability: When harm does occur in the community, there are alternative ways to ensure accountability and repair harm that do not rely on punishment, such as restorative and transformative justice practices. Research on these practices has found higher levels of satisfaction from individuals involved in the process, greater likelihood of adhering to restorative agreements, decreased rates of recidivism, decreased symptoms of PTSD, and an increased sense of fairness compared to the traditional criminal legal system. Change is within reach. While rates of incarceration in women’s prisons have skyrocketed across the US over the past decade, California’s women’s prison population has decreased by 70.8% due to significant state policy changes. California recently emptied the women’s units at Folsom State Prison, and the facility will be shut down in 2023. This is a positive step toward reducing the state’s carceral footprint, and more can be done. Given the negative health consequences of incarceration, the costs of continued investment in carceral settings outweigh the benefits. California has an opportunity to be a national leader in ending the health harm of incarceration by closing its two remaining women’s prisons, releasing the people incarcerated there — only 4% of the state’s incarcerated population — and instead investing the millions budgeted to those prisons into life-affirming, health-promoting, community-based programs that would prevent incarceration and support services to ensure a successful reentry for those being released. HumanImpact.org/HealthNotWomensPrisons 4 ACKNOWLEDGEMENTS Authors Christine Mitchell, ScD MDiv Amber Akemi Piatt, MPH Suggested Citation Human Impact Partners. “From Crisis to Care: Ending the Health Harm of Women’s Prisons.” Oakland, CA: February 2023. Contact Information Christine Mitchell, Health Instead of Punishment Project Director Human Impact Partners firstname.lastname@example.org Key Contributors First and foremost, we extend our deep gratitude to the people who are either currently or formerly incarcerated in women’s prisons in California who so openly and vulnerably shared their stories and experiences with us for this report, either via interview or survey. Thank you to Jane Dorotik, Courtney Hanson, Brian Kaneda, Zy’aire Nassirah, and Monica Ramsy without whose guidance, work, and input this report would not have been possible. Thank you to all those who attended the listening sessions and contributed your thoughts to shaping the scope of this report. Thank you to Esrea Sandon Perez Bill for your help with transcribing interviews. Thank you to Alisa Bierria, Diana Block, Colby Lenz, and Human Impact Partners staff Will Dominie, Clara Liang, Clara Long, Elana Muldavin, and Jamie Sarfeh for your helpful feedback at various stages of the writing and editing of this report. Title graphic design: Timika Orr Cover photographer: Courtney Hanson Pictured on cover: Sequette Clark, affectionately known as Mama Clark, mother of Stephon Clark killed March 18, 2018 by Sacramento Police Department Copyediting: by Clara Liang HumanImpact.org/HealthNotWomensPrisons 5 The work in this report was made possible by funding from The California Endowment. The views expressed are those of the author(s) and do not necessarily reflect the views of The California Endowment. About Human Impact Partners (HIP): HIP transforms the field of public health to center equity and build collective power with social justice movements. About Californians United for a Responsible Budget (CURB): CURB is a statewide coalition of more than 80 organizations working to reduce the number of people imprisoned in California and the number of prisons and jails in the state. We advocate for an investment in justice that centers care, not punishment. About California Coalition for Women Prisoners (CCWP): CCWP is a grassroots organization, with members inside and outside prison, that challenges the institutional violence imposed on cis and trans women, nonbinary people, and communities of color by the prison industrial complex (PIC). We see the struggle for racial and gender justice as central to dismantling the PIC and we prioritize the leadership of the people, families, and communities most impacted in building this movement. About Transgender, Gender-variant, and Intersex Justice Project (TGIJP): TGIJP is a grassroots non-profit founded with the intent to end civil right violations against incarcerated Black TGI folks in the California Bay Area and on a national level. HumanImpact.org/HealthNotWomensPrisons 6 TABLE OF CONTENTS Introduction …………………………………………………………………………………………………………… 8 Demographic makeup of California’s women’s prisons ……………………………………….. 10 California policies have successfully decreased the women’s prison population …. 11 Criminalization of trauma is a major driver of incarceration ……………………………….. 12 Criminalization of gender identity puts TGI people at particular risk …………………… 13 The Health Harms of Incarceration in Women’s Prisons …………………………………….… 14 People incarcerated in women’s prisons experience particularly poor health outcomes ………………………………………………………………………………………………………. 14 Medical neglect and abuse in prison worsen health outcomes …………………………. 16 Prison is a site of physical, emotional, and sexual trauma and violence ……….…… 19 Environmental conditions within prisons are toxic and unhealthy …………….……… 20 The use of solitary confinement creates physical and psychological distress …..… 21 The impact of incarceration in women’s prisons extends to people’s families and communities …………………………………………………………………………………..………. 22 Health-Promoting Recommendations for Alternative Investments ………….………….. 23 Invest in safe, stable, and affordable housing ………………………………………………….. 25 Invest in increased employment opportunities ……………………………………….……….. 26 Invest in affordable health care ………………………………………………………………..…….. 27 Invest in accessible and reliable transportation ………………………………………………. 31 Invest in non-carceral, non-punitive forms of accountability for harm ……………… 32 Conclusion: Closing women’s prisons in California is within reach ………………..…….. 34 HumanImpact.org/HealthNotWomensPrisons 7 INTRODUCTION “Being in prison is traumatic. It’s a depressing place, it’s an isolating feeling. We’re stripped of our rights to be with our families. It makes you feel like you are forgotten.” -Anna, 52-year-old Filipina woman, mother, student, currently incarcerated at California Institution for Women This report aims to center the experiences of people incarcerated in California women’s prisons. California has recently emptied the women’s units at Folsom State Prison, and the facility will be shut down in 2023. This is a positive step toward reducing the state’s carceral footprint, and more can be done. The research herein is focused particularly on the harmful health impacts of incarceration and the health-promoting investments needed for public health and safety, with an emphasis on reentry services in order to reduce this population's contact with the criminal legal system. The report is informed by stories and experiences from 6 interviews we conducted with people currently and formerly incarcerated in women’s prisons in California and 120 survey responses we received from people currently in California women’s prisons, in addition to existing public health literature. Quotes from the 6 people we interviewed appear throughout the report, followed by the names or pseudonyms and the identifiers chosen by the interviewees. Readers should note that the content of the report touches on topics such as attempted suicide, sexual violence, child abuse, and the violence of policing and incarceration. Though we sent surveys to people incarcerated at Central California Women’s Facility (CCWF) and California Institution for Women (CIW), we were unable to collect responses from people at CIW because the prison forbade any of our surveys from going into or out of the prison. This barrier to the report’s research methodology serves as an example of the repressive nature of prisons. Prisons actively attempt to hide the human rights abuses occurring within them by prohibiting incarcerated people from sharing their stories and experiences. We hope that this report will help to expose some of those abuses by uplifting the stories of the people we were able to hear from. HumanImpact.org/HealthNotWomensPrisons 8 ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• Notes on language regarding gender identity and gender oppression Because carceral settings and dominant discourse classify people within a gender binary, much of the data and research on the differential health impacts of incarceration divides people into male and female comparison groups. This obscures the impact of incarceration on transgender, gender variant, and intersex (TGI) people, which is problematic given that, due to discrimination and transphobia, nearly 1 in 6 transgender and gender non-conforming people are incarcerated at some point in their lives.1 Though national data are inadequate, estimates show that 21% of transgender women and 10% of transgender men report having spent time in prison or jail, compared to only 5% of all US adults.2,3 With the additive effect of racism, nearly 1 in 2 Black transgender and gender non-conforming people have experienced incarceration.1 Very little is known about how many intersex people are incarcerated. In this report, we aim to be clear and accurate with our language around gender identity and gender oppression: wherever possible, we use the phrase “people incarcerated in women’s prisons,” and specify when we are presenting research about cisgender, transgender, gender non-conforming, or intersex people. When disaggregation is not possible because of the way researchers conducted their data analyses, we use the language of the research authors (e.g. “incarcerated women”). ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• HumanImpact.org/HealthNotWomensPrisons 9 Demographic makeup of California’s women’s prisons “Black in America – you are born criminalized. You are born a suspect. And you are also born a target. So all my life I’m going to be a suspect. It doesn’t matter what I do, what I wear, I’m a suspect as long as I’m in the United States. Because that is the way the system is designed. It is designed to marginalize and criminalize certain bodies, and I happen to have one of those bodies.” -Romarilyn Ralston, 58 year old Black feminist, activist, and abolitionist, formerly incarcerated at California Institution for Women According to data from the California Department of Corrections and Rehabilitation (CDCR), in 2022, there were 3,699 people incarcerated in women’s prisons in California, 175 of whom have a sentence of life without the possibility of parole.4 The average age was 40 years old. Due to the way that racism permeates the criminal legal system, from policing to the courts to incarceration and beyond, Black people are more severely criminalized and experience a disproportionately higher rate of incarceration. This racial disparity persists in women’s prisons. In 2022, 929 people in women’s prisons were Black — 25% of the prison population, even though Black people make up only 6.5% of the California population.4 Black women in California are imprisoned at a rate of 171 per 100,000—more than five times the imprisonment rate of white women.5 Indeed, 1,173 people incarcerated in California women’s prisons are white, which is 31.7% of the prison population despite white people being 71.1% of the California population, while 1,332 are Latinx (36% of the women’s prison population) and 291 (7.9% of the women’s prison population) are labeled as “Other.”4 Finally, as of August 21, 2022, 1,628 people incarcerated in any prison in California are TGI, as identified via a survey of people chosen by CDCR to participate.6 This data is not disaggregated by prison and many people refused to participate in the CDCR survey, so these numbers are likely an underestimate. Based on the survey, in women’s prisons, there are 46 non-binary people in Central California Women’s Facility (CCWF), 22 non-binary people in California Institution for Women (CIW), and 9 non-binary people in Folsom Women’s Facility (FWF) — though the usage of “non-binary” as a monolithic category in the survey is inadequate to describe people’s identities.7 TGI people throughout California’s prisons experience HumanImpact.org/HealthNotWomensPrisons 10 profound institutional violence and this report details how this violence continues to persist. California policies have successfully decreased the women’s prison population “Women are frequently forgotten. There’s a higher expectation. Women aren’t supposed to do [harm] – so let’s lock them up, and we won’t talk about that. We won’t face that.” -MJ, 67-year-old white woman, widow, mother, currently incarcerated in California Institution for Women, formerly incarcerated in Central California Women’s Facility With the population in women’s prisons in the US skyrocketing by over 700% over the last 40 years,8 California is one of the few places in the country where the number of people incarcerated in women’s prisons has significantly decreased — from 12,668 people in 2010 to 3,699 people in 2022, a 70.8% reduction. Building on this momentum to completely divest from women’s prisons and invest in community-based supports is within reach. Several policy changes have led to the decrease: ● Assembly Bill 109: The California Public Safety Realignment Act. In 2011, the US Supreme Court ruled that California’s prison system was unconstitutional and that overcrowding was likely the source of inadequate medical and mental health care in prisons.9 Forced by this ruling, Governor Jerry Brown signed Assembly Bill 109, which shifted people who are incarcerated with lower-level convictions from the state prison system to the county jail system.10 While the entire state prison population decreased, people in women’s prisons were disproportionately affected by realignment: the number of people already incarcerated in women’s prisons decreased by 51.6% (from 12,668 people to 6,135) between 2010-2012 and the number of people entering women’s prisons decreased by 78.5% (6,701 people to 1,444).11 ● Proposition 47: The Safe Neighborhoods and Schools Act. In 2014, Proposition 47 went into effect in California, which reclassified certain theft and drug charges from felonies to misdemeanors and allowed people to petition for resentencing if they were already incarcerated for a charge that was reclassified.12 In the first year following implementation, the number of HumanImpact.org/HealthNotWomensPrisons 11 people incarcerated in women’s prisons decreased by 7.1% to 5,857 people, with another 1.5% decrease to 5,769 people in the second year after implementation.13 ● Proposition 57: The Public Safety and Rehabilitation Act. In 2016, Proposition 57 was passed by California voters, which provided opportunities for incarcerated people to reduce their sentences via participation in prison programs and created a process for people convicted of nonviolent offenses to apply for parole.14 The number of people incarcerated in women’s prisons subsequently decreased by 1.1% to 5,906 people in 2018, followed by a 3.6% decrease to 5,691 people in 2019.13 Of note, an analysis of the last decade of criminal legal system reform in California found that while the number of people incarcerated in women’s prisons declined after both AB 109 and Prop 47, the percentage of people in women’s jails increased under AB 109, before decreasing with Prop 47,15,16 indicative of the state’s use of jail transfers rather than releases under realignment. The same analysis also found that these reforms increased the disparities between Black and White adults and between Latinx and White adults, with White people disproportionately benefitting from the reforms.15 This should be an important warning for those seeking prison reform in California: policy solutions must prioritize decreasing racial inequities as well as decreasing overall reliance on incarceration to address the rampant racism in the criminal legal system. For instance, policymakers could prioritize reforming policies — such as three strikes laws, sentence enhancements, truth-in-sentencing laws, and others — that most severely and disproportionately impact Black people, Indigenous people, and other people of color.17 Criminalization of trauma is a major driver of incarceration “I was molested at 8 years old by my father’s youngest sibling. I grew up being whispered about, talked about, all these various things. And in that, I felt this huge amount of shame and guilt like I had seduced him or something at 8 years old. He wasn’t the one that did anything wrong – it was me. And that’s how I grew up.” -Lynda Axell, 68-year-old Mexican woman, she-ro, formerly incarcerated in California Institution for Women HumanImpact.org/HealthNotWomensPrisons 12 Research shows that 77% to 90% of people incarcerated in women’s prisons report having experienced prior emotional, physical, and/or sexual abuse,18 with some estimates as high as 98% having experienced interpersonal violence at some point prior to incarceration.19 One study found that 53% of women incarcerated in jails meet clinical criteria for post-traumatic stress disorder (PTSD), compared to only 10% in the general population.20 A lack of community-based mental health services and survivor-focused violence intervention, as well as the criminalization of survival behaviors (such as self-defense in abusive relationships and engaging in sex work or shoplifting to survive), create the conditions for traumatic events to lead to loss of employment, loss of housing, loss of child custody, mental health consequences, and incarceration.21 This research bears out in our survey of people incarcerated in women’s prisons in California. Forty-three percent of survey respondents reported that intimate partner violence played a role in their criminalization and/or incarceration, with several respondents noting that the trauma of either their own childhood abuse or witnessing abuse of their own children were factors. Rather than addressing the root of people’s needs through supportive services, incarceration perpetuates further violence and trauma. One evaluation of a trauma-specific program called “Healing Trauma: A Brief Intervention for Women” in two California prisons found that the strongest significant predictor of inflicting violence or intimidation as an adult was being criminalized as a young person. The second strongest predictor was experiencing abuse before the age of 18.22 Criminalization of gender identity puts TGI people at particular risk “I was incarcerated at the age of 17. My incarceration dealt with my gender identity. I was abused for my gender growing up. And basically, I fought back and I went to prison… You have somebody who’s a kid, and they had anger, or made a mistake, now they’re incarcerated. You’re only further impacting the trauma that I came in with. I came from a house where there was yelling. Now I’m in a prison where people are yelling. I came from a house that was abusive. Now I’m in a prison that’s abusive.” -Malcolm, 50-year-old Black man, advocate for trans rights and justice, formerly incarcerated in Central California Women’s Facility and California Institution for Women HumanImpact.org/HealthNotWomensPrisons 13 Discrimination against transgender, gender non-conforming, and intersex (TGI) people creates harm from childhood through adulthood. Due to this discrimination, TGI people disproportionately experience family rejection and isolation, suspension and expulsion from school, low household income and lack of employment opportunities, high rates of eviction and refused housing, and inadequate and discriminatory medical care.2 In the National Transgender Discrimination Survey, 57% of transgender adults reported experiencing family rejection and isolation, with greater likelihood of being unhoused, using substances, or being incarcerated.1 Alarmingly, 41% of respondents reported attempting suicide, while only 1.6% of the general population has reported suicide attempts. TGI people who experienced unemployment, bullying in school, low household income and sexual and physical assault reported even higher rates of suicide attempts.1 Each of these internalized, interpersonal, and systemic struggles increase the risk of criminalization (e.g., being policed, incarcerated, fined, punished) and do irreparable harm to the health and well-being of TGI people, particularly for Black, Indigenous, and people of color. Discriminatory policies and policing practices also lead to the disproportionate criminalization and incarceration of TGI people. One survey found that one in five (22%) transgender people report being mistreated by police.2 The Health Harms of Incarceration in Women’s Prisons People incarcerated in women’s prisons experience particularly poor health outcomes “There’s no way of becoming healthy in an environment that doesn’t provide any care. There's no mental health care, there’s no medical care, there’s inadequate food, there’s inadequate housing, there’s inadequate environmental conditions, everything about the prison is unhealthy. So there’s no way for a sick person entering into this system to ever get well.” -Romarilyn Ralston, 58-year-old Black feminist, activist, and abolitionist, formerly incarcerated at California Institution for Women HumanImpact.org/HealthNotWomensPrisons 14 ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• COVID as a case study for incarceration’s harm to health “When we got to quarantine, I didn’t have a mattress for 2 days. I was sleeping on a steel bed. They were denying us toilet paper. Thirty-two days of being in quarantine, I was able to bleach my toilet one time. And I had a roommate who had COVID as well. They denied us showers for 5 days and denied me phone calls to my family for 3-4 days.” -April Harris, 46-year-old Black woman, currently incarcerated at California Institution for Women The COVID-19 pandemic has provided a horrifying case study of how incarceration harms health. With overcrowding, poor sanitary conditions, insufficient testing, and refusal to provide personal protective equipment, the COVID case rate in prisons was 5.5 times higher than the case rate in the general US population, according to early analyses.27 “Quarantine” in prison meant forcing people who tested positive into solitary confinement or cells without access to mattresses, clean water, or medical care. These inhumane conditions actively deterred people from reporting symptoms, which only exacerbated the spread of infection. In California, CDCR has recorded over 90,000 cases of COVID and 260 deaths across all state prisons since the start of COVID, with 3,262 cases and 2 deaths in women’s prisons.28 As part of efforts to mitigate COVID in state prisons, CDCR expedited the releases of over 7,500 people. However, most of those released had less than a year remaining on their sentences, while thousands of disabled, immunocompromised, elderly, and otherwise high risk people remained in prison.29 While not nearly enough to diminish the harm of COVID in prisons, or incarceration in general, these efforts showed that decarceration is achievable. In order to prevent future and ongoing harm, the state of California needs to stay committed to releasing as many people as possible, as quickly as possible, while investing in the supports people need upon reentry. ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• HumanImpact.org/HealthNotWomensPrisons 15 There is an abundance of evidence that — due to the experience of incarceration and exposure to harmful social and structural determinants of health prior to incarceration — incarcerated people of all genders have worse health outcomes than the general US population, including a greater likelihood of having asthma, cancer, arthritis, high blood pressure, and infectious disease.23 However, those incarcerated in women’s prisons face an even higher rate of health risks than currently and formerly incarcerated men. For example, currently incarcerated women are more likely to have a history of substance use, depression, high blood pressure, and sexually transmitted infections.24 In part, the gendered difference in health risks begins before incarceration: people incarcerated in women’s prisons experience greater trauma and abuse, less frequently access community healthcare services, and more frequently enter prison reporting greater mental health needs than people incarcerated in men’s prisons.25 Once incarcerated, the specific healthcare needs of people in women’s prisons, such as hormone treatments and obstetric and gynecological concerns, are more often unmet. For TGI people in particular, discrimination and abuse is amplified in prison, leading to higher disease and death rates than cisgender women in prison.26 In our survey, 83% of people reported having an illness or disability, with 55% reporting having 3 or more health conditions needing care. Medical neglect and abuse in prison worsen health outcomes “When [TGI] individuals are put on hormonal treatment [in prison], they just take your blood and put you on it, but there’s no follow up. It should not just be a handout we give you, because a handout is not treatment. I know that some hormones can cause cancer – you’re not saying that. You’re not telling people they need to drink enough water. You’re not saying this is the diet you need, this is how much water they need. So I think there’s big neglect when it comes to that.” -Malcolm, 50-year-old Black man, advocate for trans rights and justice, formerly incarcerated in Central California Women’s Facility and California Institution for Women In 2000, recorded legislative hearings inside California’s women’s prisons documented people’s experiences. Overwhelmingly, those who testified named that lack of access to medical care and appropriate treatment was their primary concern.30 Participants in our survey affirmed this concern as well, with 83% of respondents reporting that they had experienced medical abuse or neglect while imprisoned. Rampant medical neglect in carceral settings is well documented. One HumanImpact.org/HealthNotWomensPrisons 16 study found that among chronically ill people in state prisons in the US, 20.1% had not received a medical examination since incarceration. Furthermore, almost 30% of people in federal and state prisons reported they didn’t receive needed prescriptions upon incarceration.31 Communication between medical staff and prison staff is poor or non-existent, leading to medical errors and neglect.32 Seventy-two percent of our survey respondents said that they had to wait a long time to receive treatment for something they were diagnosed with, or for an injury that prison officials knew about. People in women’s prisons face particularly escalated medical abuse and neglect related to reproductive health. One study found that 25% of people in women’s prisons were pregnant or had recently delivered a baby, but only 54% reported that they received any form of prenatal care.33 Forty percent of respondents to our survey reported experiencing reproductive abuse, such as coerced sterilization or an untreated reproductive health issue while imprisoned. Forced sterilization has a long and sordid history in prisons, especially in California. Under eugenicist state laws, California forcibly sterilized over 20,000 people both in the general population and in prisons from 1909 to 1979, particularly disabled people and those with mental health needs.34 In 1979, California overturned sterilization laws among the general population of the state, but not the prison population. Within prisons, doctors forcibly sterilized people until 2014. Though longitudinal data is incomplete, 1,400 sterilizations were documented in California state prisons between 1997 and 2013.35 In at least 148 instances, CDCR medical staff sterilized people via tubal ligation after they gave birth in prison. The majority of those women were Black and Latina. Beyond this, an unknown number of cis and transgender people were sterilized while seeking treatment for other abdominal concerns.35 TGI people also face particular neglect by not receiving gender-affirming care in prison. In a 2017 study, researchers found that only 8 states, including California, provided gender-affirming surgeries for incarcerated TGI people. In the rare instance that gender-affirming surgeries are provided, there is little to no post-operative care. The same study found that prisons in 27 states would not initiate hormone treatment for TGI people and prisons in 20 states discontinued hormone treatment for those who had been receiving this care prior to incarceration.26 The National Transgender Discrimination Survey found that 9% of incarcerated transgender men who participated in the survey reported denial of hormone treatment, despite legal precedent declaring this as cruel and unusual punishment.3 Denial of this care for incarcerated TGI people can have catastrophic consequences, including increased rates of depression, self-injury, and suicide.26 HumanImpact.org/HealthNotWomensPrisons 17 Respondents to our survey reported several aspects of neglect that they face while incarcerated: Medical staff failed to investigate my medical complaint because they: CO did not refer my complaint to medical staff Did not consult my medical records before stopping medication Had long delays in receiving mental health assessment Did not accurately document my complaints Did not order diagnostic tests Did not investigate the cause of my medical condition Did not send me to a specialist Did not properly treat me 0% 10% 20% 30% 40% 50% 60% 70% ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• Disabled people are disproportionately criminalized and harmed by incarceration Due to the impacts of social ableism via higher rates of being policed, socioeconomic marginalization, and discrimination in the medical sector and legal sector, disabled people are disproportionately represented in prisons. Sixty six percent of the incarcerated population is disabled: 40.4% with a psychiatric disability and 56.0% with a non-psychiatric disability.36 A higher percentage of people incarcerated in women’s prisons reported disability (79.5%) compared with people incarcerated in men’s prisons (64.6%).36 Medical neglect and the physical and emotional conditions of incarceration can both create and exacerbate disability, including via the denial of needed accommodations or assistive devices.36 The decarceration of disabled people is urgently important, along with the provision of automatic eligibility for Medicaid upon reentry to ensure no gaps in needed care. ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• HumanImpact.org/HealthNotWomensPrisons 18 Prison is a site of physical, emotional, and sexual trauma and violence “I have certainly never been threatened, never been in a fight, never had any kind of a write-up. But it's very distressing to see those here. To see the violence, the anger, the abuses that are definitely present here.” -MJ, 67-year-old white woman, widow, mother, currently incarcerated in California Institution for Women, formerly incarcerated in Central California Women’s Facility In 2012, research on violence within prisons found that 89% of incarcerated people in the study believed that “violence in prison is inevitable.”37 Many in prison have experienced physical, verbal, or sexual violence, with many more regularly witnessing it. For example, one study of 17,640 incarcerated people found that 13% of people in prisons across the US experienced violence while incarcerated.38 Another study of 1,642 people recently released from men’s prisons found that around 60% had experienced some form of victimization in prison (including theft, fighting, emotional abuse, and sexual assault) while 98% had witnessed victimization of others.39 Both experiencing and witnessing violence can adversely affect health. People incarcerated in women’s prisons again face particular violence within the system. In our survey, 47% of respondents experienced sexual and/or gender-based violence while imprisoned. In one study of people incarcerated in women’s prisons, as many as 19% of participants reported that they had been sexually assaulted while incarcerated and that 45% of those assaults were by prison staff.33 Due to transphobia, transgender people experience even higher rates of violence in prisons and jails, with one study finding that transgender people incarcerated in California men’s prisons were 13 times more likely to experience sexual assault than cisgender men in the same prisons.40 Survey data finds that 47% of formerly incarcerated transgender women reported victimization or mistreatment (including physical assault, sexual assault, harassment, or denial of medical care) in prison,41 44% of transgender men in women’s prisons reported harassment by prison staff, and 29% of transgender men in women’s prisons reported harassment by other incarcerated people.3 With the additive impact of racism, incarcerated Black and Latina transgender women are even more likely to report experiences of victimization.42 HumanImpact.org/HealthNotWomensPrisons 19 Environmental conditions within prisons are toxic and unhealthy “We’re dying alone here. The water is questionable. Proven unsafe to drink but they still make us drink it. Now I have had H pylori from drinking the water, I have high blood pressure now, and because of COVID, my lungs are compromised, but I can’t ask for help because then they’ll quarantine me for COVID symptoms.” -April Harris, 46-year-old Black woman, currently incarcerated at California Institution for Women The conditions within prisons are notoriously toxic, including overcrowding, which can lead to rapid spread of infectious disease, as seen during the COVID-19 pandemic.43 Prison conditions also seriously endanger the health of incarcerated people, including exposing them to extreme heat and cold, inadequate food, foodborne illness, mold, and toxic drinking water.23 A majority of participants in our survey reported being exposed to these environmental health and safety hazards: Environmental Hazards in CA Women's Prisons (% reported) Unsanitary food service Excessive heat Inadequate ventilation Mold ===;;;;;========;;;;;;;==;;;;;;;==;;;;;;;;======a3y., =======================-s2% =============:::::;:=========:::::;=:i'.8_'¾i Polluted water Inadequate food =============:::::;:======:::;:::lil'¾i Excessive cold Insects Rodents and other vermin Toxic or noxious fumes Constant lighting Exposure to sewage ====::::::::==:::::===::3:3 Asbestos Lack of fire safety :::::::==::::::::~.18% 0% 10% HumanImpact.org/HealthNotWomensPrisons 20% 30% 40% 50% 60% 70% 80% 90% 20 The use of solitary confinement creates physical and psychological distress “I’ve been in solitary. It’s inhumane. People had to beg for feminine hygiene, they had to beg for a razor. I was told that I had to put on a dress to go there. You are at the guards’ mercy. If they feel like giving you a tray, you get your tray. And basically you’re just really locked in a cell.” -Malcolm, 50-year-old Black man, advocate for trans rights and justice, formerly incarcerated in Central California Women’s Facility and California Institution for Women In 2011, the United Nations Special Rapporteur on torture stated that the use of solitary confinement — known by CDCR as administrative segregation or the Secure Housing Unit (SHU) — should be banned as a form of punishment.44 Still, solitary confinement is used regularly in carceral settings. In women’s prisons, people with mental health concerns are often put into psychiatric segregation units rather than provided with needed support, leading to fear of telling prison medical staff about mental health needs.30 In a 2015 survey conducted by Black and Pink, 85% of the 1,100 LGBTQ incarcerated respondents — and particularly transgender women — reported having been involuntarily put into solitary confinement.2 While a few men’s prisons in the US have separate units specifically for LGBTQ incarcerated people, no women’s prisons provide this setup, meaning that transgender men in women’s prisons are frequently placed in solitary confinement, rather than allowed to be in the general population and not locked in their cells for most of the day.3 The health impacts of solitary confinement are adverse and far reaching. The experience can lead to increased psychological distress, including anxiety and depression. One study found that people who had been in solitary confinement were three times more likely to have symptoms of PTSD compared to those who had not.45 Other psychiatric effects of this type of confinement include sleep deprivation, paranoia, agitation, and increased prescription of sedative medications.46 Beyond the mental health impacts, solitary confinement can also harm physical health. Research finds that people often develop bed sores, weight loss, rashes, dry skin, and fungal growth while in solitary due to the even poorer and more restrictive environmental conditions in these units.45 Another study found that people who had been in solitary confinement were 31% more likely to have hypertension than people who hadn’t.47 The experience can even affect life expectancy: a study of formerly incarcerated people in North Carolina found that HumanImpact.org/HealthNotWomensPrisons 21 people who had been in solitary confinement were 24% more likely to die in their first year after being released from prison than those who hadn’t.45 The impact of incarceration in women’s prisons extends to people’s families and communities “My granddaughter that I’m the closest with, she’s 21 now. She remembers some things from when I was arrested and feels like I was taken from her – and it has caused her life to have a hole in it. And her younger brothers, they never had me out there, so they have a lot of anger that they deal with because of it.“ -MJ, 67-year-old white woman, widow, mother, currently incarcerated in California Institution for Women, formerly incarcerated in Central California Women’s Facility Incarceration of any form separates people from their families and communities, with destructive consequences. Over 60% of people incarcerated in women’s prisons are mothers of children under the age of 18. Prior to their incarceration, these mothers were often the sole caregiver for their children.48 Until the recent growth in incarceration rates in women’s prisons across the US, most states only had one women’s prison, often geographically distant and isolated from people’s children, families, and community resources.49 This distance makes it both logistically and financially difficult for family members to visit, causing many parents to lose touch with their children.48 The carceral and punitive logic of the family policing system means that children with incarcerated mothers are at high risk of being placed in foster care and mothers are at risk of having parental rights terminated.48 All of this can have lifelong consequences for children of incarcerated parents and is linked to attention difficulties, aggression, and negativity.50 Adverse consequences also extend to adult partners and other family members, creating relationship strain and increased risk of depression and anxiety.51 Due to both interpersonal and systemic homophobia and transphobia, LGBTQI+ people are at particular risk of losing social support during and after incarceration. One study among Black transgender women and queer Black men found that those who were recently incarcerated had a 50% higher risk of not having the emotional support of someone to talk to and to listen to them.52 People in this study who were recently incarcerated were also 1.8 times more likely to lack key forms of material, emotional, and social support one year after imprisonment.52 HumanImpact.org/HealthNotWomensPrisons 22 Incarceration can also affect families by creating economic instability. One study found that 48% of families with an incarcerated family member have difficulty meeting basic housing needs because of the loss of a source of income.53 Being behind on rent is linked to worse caregiver health, maternal depressive symptoms, child lifetime hospitalizations, worse child health, and household material hardships.54 Being in any debt at all — which is easy to accumulate with a loved one incarcerated, due to lost income, court fines and fees, fees for phone calls and emails, and more — is associated with higher perceived stress and depression, worse self-reported general health, higher diastolic blood pressure, sleep deprivation, and anxiety.55 Finally, emerging public health research finds that incarceration has an impact even on non-incarcerated community members in communities with high incarceration rates, whether or not they themselves personally know someone incarcerated. For example, after controlling for other neighborhood factors, research finds that communities with high incarceration rates are associated with a 2.5% increased rate of county-level mortality,56 as well as significantly greater odds of individual-level preterm birth,57 lifetime major depressive disorder, and lifetime general anxiety disorder.58 Health-Promoting Recommendations for Alternative Investments “It’s just different when you show people love and support. It changes them. And I believe in redemption. I really do.” -Anna, 52-year-old Filipina woman, mother, student, currently incarcerated at California Institution for Women Rather than continuing to invest $405 million59 in health-destroying women’s prisons in California, the state has the opportunity to instead invest that money in health-promoting support systems that people can access in their own communities. These public safety investments would not only support reentry after incarceration, they would also help to prevent harm from occurring in the first place, creating the conditions that would make women’s prisons obsolete. We can create systems of care and accountability that do not rely on punishment and that ensure that people have what they need to live safe and healthy lives. Investing in HumanImpact.org/HealthNotWomensPrisons 23 reentry resources helps support the health and well-being of the entire community, including those who have never been incarcerated. When asked in our survey which critical reentry resources they would need when they left prison, people incarcerated in California women’s prisons most frequently responded with a need for housing, employment, mental health and substance use support, healthcare, transportation, identification documents, and clothing. The next section of this report will take a deeper look at the evidence base for investment into these social determinants of health. ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• Recidivism and crime rates are inadequate and problematic measures of successful reentry Much of the existing research in public health and other fields measures the success of reentry by recidivism/re-incarceration rates and crime rates. Given the state of the research, this report does discuss those outcomes. However, it’s important to note that both of these are inadequate measures of success. Firstly, recidivism and crime rates reflect arrest and incarceration data, which most accurately measure distributions of policing. Crime is both a legally defined set of laws and a social catch-all idea; neither meaningfully reflects true rates of intrapersonal, interpersonal, institutional, or structural harm. Secondly, much of the data that we have about recidivism and crime comes from the police, making the data biased and incomplete at best, and falsified at worst. Thirdly, there are also myriad other understudied factors that contribute to someone’s successful reentry, including measures of health outcomes, social support, economic security, stable employment and housing, and more. Focusing solely on recidivism reduces a person’s life to their interactions with the criminal legal system, disregarding all of the other structural and political barriers that might prevent a person from thriving after incarceration — including housing, employment, transportation, food, and healthcare.60,61 ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• HumanImpact.org/HealthNotWomensPrisons 24 Invest in safe, stable, and affordable housing “There’s not enough housing for women, there’s not enough housing for people who served long sentences, there’s not enough re-entry housing that’s transformative, that is ADA compliant, that allows people to re-integrate at their own pace. Money should be poured into supporting individuals and communities. Healthy communities make healthy people. Healthy people make healthy communities.” -Romarilyn Ralston, 58-year-old Black feminist, activist, and abolitionist, formerly incarcerated at California Institution for Women Due to discriminatory housing policies and practices, 1 in 11 people recently released from incarceration experience houselessness, compared to 1 in 200 for the general population,62 and those who have been incarcerated more than once experience houselessness at twice the rate of those returning to their communities after their first prison sentence.63 The risk of houselessness for people returning from women’s prisons is even higher: people formerly incarcerated in women’s prisons experience houselessness at 1.4 times the rate of people formerly incarcerated in men’s prisons.63 With the additive impact of racist housing policies, Black people formerly incarcerated in women’s prisons experience the highest rate of houselessness, at nearly 4 times the rate of white men, and 2 times the rate of Black men.63 Even without the barrier of a criminal record, transgender people face high rates of discrimination that lead to housing insecurity, denial of housing, and eviction, made worse for those who are formerly incarcerated.64 Being unhoused impacts successful and healthy reentry along multiple pathways. It can contribute to the cyclical nature of the criminal legal system by leading to re-incarceration due to the criminalization of houselessness. The public nature of being unhoused creates the conditions for police to target people for acts of survival and arrest or cite people for what the law refers to as “quality-of-life crimes,” like camping, loitering, and public urination.65 A survey conducted between 2015 and 2017 by California Policy Lab found that unhoused people reported an average of 21 contacts with police in the previous six months.65 While transitional housing or shelters can serve as a temporary solution during reentry, even those are often unsafe for transgender people. The 2015 US Transgender Survey found that 70% of transgender people who stayed in a shelter experienced harassment, abuse, or mistreatment.66 Investments in transitional housing for transgender HumanImpact.org/HealthNotWomensPrisons 25 people, like the Alexia Norena House in Massachusetts, are essential for TGI people returning to their communities.67 Alongside decriminalizing houselessness by ending the practice of targeting people for quality-of-life crimes, it is essential to ensure that people returning from women’s prisons can access safe, stable, and affordable housing. Governments should prioritize investments in housing and the supportive programs that people need to stay housed. An evaluation of a supportive housing program for those who had previously cycled in and out of jails in New York City found that, after one year, 91% of those who participated in the program were in permanent housing, compared to 28% of those who did not participate. After 2 years, that percentage had only slightly dropped to 86%. Participants in the program also reported reduced substance use rates, improved psychological stress, and increased family and social support.68 Importantly, programs that provide housing to previously incarcerated people without conditions such as sobriety or employment are more effective at keeping people housed long term.69 It is also essential to remove discriminatory practices and policies that prevent people from accessing housing. This includes passing Fair Chance housing policies,70 which prohibit blanket discrimination of tenants based on past incarceration; restricting “crime free housing” practices, which exclude people with records in private development;71 and reducing exclusions in housing funded by the Department of Housing and Urban Development to the minimums mandated by federal law.72 Invest in increased employment opportunities “I saw this one psychiatrist [in prison] and she told me, I can tell you this much, if you don’t have a place to go to, and if you don’t have a means of support, they will never ever let you out.” -Lynda Axell, 68-year-old Mexican woman, she-ro, formerly incarcerated in California Institution for Women Employment discrimination against formerly incarcerated people is well documented. One of the first national estimates found that the unemployment rate for formerly incarcerated people — around 27% — is nearly 5 times higher than that of the general population, and higher than the US unemployment rate at any point in history.73 In one well-known study, researchers sent out pairs of resumes to employers: matched pairs of a white candidate with a criminal record and one without, and matched pairs of a Black candidate with a criminal record and one HumanImpact.org/HealthNotWomensPrisons 26 without. The study found that not only did having a criminal record reduce the likelihood of getting a callback by 50%, but also that racism led to white people with a record still being more likely to receive a callback than Black people with no record.74 When adding gender oppression as an additional factor, formerly incarcerated Black women experience the highest unemployment rates at 43.6%, while formerly incarcerated white men’s unemployment rate is 18.4%.73 Unfortunately, little data is available on the unemployment rate for formerly incarcerated TGI people, but given that non-incarcerated TGI people already face employment discrimination leading to twice the rate of the national unemployment rate (14% compared to 7%), it is likely that rates are high for formerly incarcerated TGI people.1 Supporting employment opportunities for formerly incarcerated people benefits both the employer and the employee. One longitudinal study found that after “banning the box” on job applications — prohibiting employers from asking about an applicant’s criminal record — organizations that hired applicants with criminal records exhibited a lower turnover rate in their employees than organizations that didn’t.73 Another found that among call center employees, those with criminal records stayed on staff for longer and had lower rates of quitting.73 For formerly incarcerated people, employment is a pathway into health via economic security, housing stability, adequate nutrition, and accessible healthcare. One study found that the positive benefits of employment included not only lower rates of recidivism but also a sense of identity and meaning for formerly incarcerated employees.75,76 Invest in affordable health care “[After prison,] I saw an attending physician, and I told them everything I needed, after three times trying to get in there, and he said we will call you within a week. That was a month and a half ago. So, if I had to say anything – what we need [outside prison] is to expedite medical care, whether it be physical or mental health.” -Lynda Axell, 68-year-old Mexican woman, she-ro, formerly incarcerated in California Institution for Women Community-based mental health care Formerly incarcerated cisgender women and TGI people, who often carry extensive histories of emotional, physical, and sexual trauma and violence prior to and during HumanImpact.org/HealthNotWomensPrisons 27 incarceration, have very high rates of mental health needs. In one study, 44% of people formerly incarcerated in women’s prisons reported that they had been diagnosed with some mental health concern, including bipolar disorder, depression, obsessive compulsive disorder, PTSD, or schizophrenia, and 56% felt that they currently needed treatment for these concerns.77 Another study found that among people formerly incarcerated in women’s prisons with mental health needs, 80.3% reported also struggling with substance abuse and 67% reported also having a physical health concern.77 The increased incidence of harassment and assault of TGI people inside prisons is associated with a range of negative mental health outcomes for those reentering, including depression, anxiety, PTSD, and suicidality.78 The need for mental health support for those returning to their communities from women’s prisons is high, and research shows the positive impact of investing in more accessible and affordable care. Provision of mental health care can prevent future crime and re-incarceration. One study found that — after controlling for other factors that might impact crime rates and the presence of community mental health centers — the more mental health care offices there were in a county, the lower crime rates and crime costs were in that county. Strikingly, 10 additional mental health care offices was associated with a 2.2% reduction in crime costs in a county.79 Studies of cognitive behavioral programs report between 8% and 32% reductions in reincarceration and other therapeutic and behavioral interventions report between 14% and 24% reductions in reincarceration amongst formerly incarcerated people, compared to those without access to such programs.80 More investment in both professionalized treatment and non-professionalized community-based supportive care is important for those who may need more intensive amounts of mental healthcare. The current system of involuntary commitment in inpatient psychiatric facilities can often be sites of abuse and trauma rather than healing. Many studies find that there is extreme risk for suicide during the first few months after someone is discharged from inpatient psychiatry, and that only about 50% of patients have a follow-up visit with a healthcare professional within the first month after discharge.81 In order to truly support people’s mental health, investments need to be made in providing wraparound support services within people’s communities.82,83 Programs such as those sponsored by the Transitions Clinic Network are successful at connecting recently released people to care. One study found that among women recently released from incarceration, 86% of those with a mental health HumanImpact.org/HealthNotWomensPrisons 28 concern who were connected to the Women’s Initiative Supporting Health Transitions Clinic received mental health treatment. For every additional mental health concern reported, women were 4.1 times more likely to receive treatment when connected to care.84 Ensuring that such care is provided to TGI people leaving prison is also essential. Substance use treatment Many people incarcerated in women’s prisons report using substances to cope with the trauma and violence they have faced in their lives. The risk of overdose in the first two weeks post-release is as much as 129 times higher than that risk in the general, non-incarcerated population.85 People incarcerated in women’s prisons are more likely than people incarcerated in men's prisons to report using drugs, with 65% to 85% of those in women’s prisons disclosing substance use. People incarcerated in women’s prisons are also twice as likely as those incarcerated in men’s prisons to have co-occurring substance use and mental health needs.86 Transgender women who have been incarcerated are 1.4 times more likely to report using substances to cope than transgender women who have not been incarcerated, and two times more likely to report doing so if they faced mistreatment or neglect while incarcerated.41 Investing in community-based substance use treatment centers has important positive outcomes. One study found that every additional substance use treatment center in a community reduced crimes classified as felonies by 0.10% annually.87 In the same study as above, of people formerly incarcerated in women’s prisons connected to the Women’s Initiative Supporting Health Transitions Clinic, 64% of those who reported using substances received treatment when they were provided with access to this kind of care.84 Ultimately, drug decriminalization policies combined with investment in substance use treatment options will be most effective at improving health outcomes. For example, in 2018, the Drug Policy Alliance did an analysis of drug decriminalization in Portugal — one of the most often upheld examples of decriminalization in the world — after 70 advocates traveled there from the US to examine the effects of Portuguese drug policies. They report the enormous benefit of decriminalization on health: overdose deaths decreased by over 80% after the country decriminalized drugs, to a rate of 5.2 per million in 2015.88 For comparison, the rate of drug overdose deaths in California in 2015 was 113 per million, which is nearly 22 times higher than the rate in Portugal.89 Drug decriminalization in Portugal has also HumanImpact.org/HealthNotWomensPrisons 29 improved HIV/AIDS outcomes, with people who use drugs making up 52% of new HIV/AIDS cases in 2000 (prior to decriminalization) and dropping to only 6% of new cases by 2015.88 By investing in treatment services in tandem with decriminalization, the number of people in drug treatment increased by over 60% between 1998 and 2011.90 Physical health care The burden of physical health concerns is also high for people returning to their communities after incarceration in women’s prisons. A 2014 study found that 2/3 of a group of women formerly incarcerated in Houston, TX reported having a serious physical health problem: 23% reported high blood pressure, 25% reported asthma, 15% reported back problems, and 15% reported hepatitis.77 Many respondents to our survey of people incarcerated in California’s women’s prisons qualitatively reported that they had these same medical concerns and more, including diabetes and lingering effects of long COVID. Because of many of the aforementioned structural factors, reports of HIV rates are among the highest of any demographic for transgender women, especially for transgender women of color, and even higher for those who are formerly incarcerated.41 Addressing these needs immediately following incarceration is essential, since interruption of HIV antiretroviral therapy can be immensely harmful.91 Similarly, interruption of hormone treatments or other gender-affirming care for transgender people could lead to increased risk of depression, suicidal ideation, or suicide attempts92 and must be prioritized for transgender people being released from prison. Affordability is a primary barrier to accessing care upon reentry, with 80% of formerly incarcerated people uninsured in 2014.93 Therefore, societal and governmental investments in affordable health care are essential. Returning to the study of those connected to Women’s Initiative Supporting Health Transitions Clinic during reentry, having this connection ensured that patients received preventative care such as hepatitis A/B/C testing and vaccinations, STI testing, mammograms, colonoscopies, and pap smears.84 To address affordability of care, there is bipartisan support across the country for federal and state-level legislation that would expand Medicaid access for incarcerated people pre-release to ensure continuity of care upon reentry,94 and states that already have this policy enacted have seen positive results in connecting people to healthcare upon reentry.95 Medicaid expansions not only improve health outcomes and health equity, but also could be a stopgap in the revolving door of re-incarceration, with research showing HumanImpact.org/HealthNotWomensPrisons 30 that Medicaid expansion reduced violent crimes by 5.8% and property crime by 3%.96 Invest in accessible and reliable transportation “I think I was in my fourth year here when I had this class with a professor who said, “What are you going to do if the warden walks in here and gives you parole? Are you ready to go home?” So every year after that, I [think about that question] and I prepare. And yes, my mom is going to give me a car, my son said he’s going to drive me around.” -Anna, 52-year-old Filipina woman, mother, student, currently incarcerated at California Institution for Women Though transportation was one of the most frequently endorsed needs from our survey respondents, there is still a great need for research exploring the scope of the issue for people returning to their communities after incarceration, particularly in women’s prisons. For those going through reentry, an accessible and reliable form of transportation is necessary for accessing needed healthcare and support services, mobilizing in case of emergency, connecting with their families and loved ones, and maintaining stable employment. However, research finds that many people returning from women’s prisons do not have access to a personal vehicle. One study that surveyed women on parole or probation who use substances found that 68% of respondents did not own or lease their own vehicle, 37% did not have access to someone else’s vehicle, and 58% did not have a valid driver’s license.97 The same study found that more than a third of the respondents had difficulty obtaining a car for work or emergencies and nearly 25% reported difficulties accessing public transportation.98 Public transportation can be unreliable, unsafe, inaccessible, or inconvenient, with a formerly incarcerated woman in one qualitative study noting that her transportation needs might require up to 4 hours of traveling on public transit in one day.99 Because of the way it touches almost every aspect of a successful reentry, when a need such as transportation is not met, health outcomes worsen and likelihood of re-conviction increases. Lack of access to reliable transportation can lead to mental health impacts such as increased stress, which can then contribute to decreased attendance and productivity at work, interrupted family and community cohesion, and physical health correlates, among other impacts.97 One study looking at recidivism prevention among formerly incarcerated transgender women used HumanImpact.org/HealthNotWomensPrisons 31 geospatial mapping and in-depth interviews to find that lack of access to transportation was a barrier to employment, probation or parole appointments, as well as transgender-inclusive health care.100,101 Analyses conducted on data from women on parole or probation used a transportation access score to find that for every unit improvement in this score, women’s odds of re-conviction decreased by 1.5.102 Invest in non-carceral, non-punitive forms of accountability for harm “[My vision of a better world starts with] no judgment. Trans [people] and every individual would get to be themselves. Every individual would have access to housing, every individual would have access to medical care, every individual would have therapy if they need it. We’ll have parenting classes, we’ll have re-entry support, we’ll have restorative justice, we’ll have transformative justice. There would be no retribution.” -Malcolm, 50-year-old Black man, advocate for trans rights and justice, formerly incarcerated in Central California Women’s Facility and California Institution for Women When harm does occur in the community, there are alternative ways to ensure accountability and repair harm that do not rely on punishment. Restorative justice is a non-punitive, non-retributive process that addresses interpersonal harm by bringing together those involved to collectively decide how to repair the harm caused. Transformative justice builds upon this process by also considering the larger systems and structures that created the conditions for harm to occur.103 Though more research evaluating transformative justice practices is needed, there is robust research on restorative justice as a means of repairing harm without punishment. One meta-analysis on restorative justice revealed higher levels of satisfaction from individuals involved in the process, greater likelihood of adhering to restorative agreements, and decreased rates of recidivism compared to those who did not participate in a restorative justice process.104 Another study found that those who had been harmed and underwent a restorative justice process had decreased symptoms of post-traumatic stress disorder.105 Much of the research on restorative justice focuses on its effectiveness in practice with young people. A meta-analysis of restorative justice programs with young people under 18 found decreased re-engagement with the legal system, an increased sense of fairness among both the young people who did harm and the people who were harmed, and increased satisfaction when compared to those who HumanImpact.org/HealthNotWomensPrisons 32 did not participate in restorative justice programs.106 Another study of a middle school in Oakland, California that implemented restorative justice practices found an 87% drop in suspensions, compared to the previous three years, and a complete elimination of expulsions in the first two years of implementation.107 Further investment in programs like this, both among youth and among the general population, holds great promise for supporting healing among those who have been harmed and accountability among those who have done harm. ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• Unconditional release is most conducive to a healthy and successful reentry “You do your time, then you have parole, and then all of a sudden you’re free. But you’re never free when you have that background, that felony background, even with a pardon. My crime isn’t expunged, you know, so I’m never gonna be free. I’m always going to be subjected to scrutiny and moral tests, character references. It will never end for me, and just knowing that is a cost and burden and harm.” -Romarilyn Ralston, 58-year-old Black feminist, activist, and abolitionist, formerly incarcerated at California Institution for Women A limited but growing body of research shows that the conditions of release matter for successful reentry. Recent studies have found that formerly incarcerated people perceived themselves to be less employable and have lower job quality the more stipulations they had to meet for probation and parole — especially meetings with probation/parole officers or courts.108 Research is clear that low job quality and lack of employment availability have an immense adverse impact on mental and physical health and may even reverse any positive impact that employment has on health.109 Release conditions like electronic monitoring are also harmful to health. The last two decades have brought about exponential expansion of electronic monitoring, with the use of ankle monitors in the US increasing by 140% from 2005 to 2015.110 In Los Angeles County, electronic monitoring increased by 5,250% from 2015 to 2022.111 Most directly, ankle monitors can cause foot swelling, cramps, and burning of the skin as the ankle monitor charges.112 Electronic monitoring creates a system of carceral surveillance that extends ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• HumanImpact.org/HealthNotWomensPrisons 33 ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• beyond prison walls to continue to restrict movement and privacy, interfere with family and intimate relationships, and jeopardize employment, economic security, and housing opportunities — all of which have negative repercussions for health.113 Furthermore, in a national comparison between people released from state and federal prisons conditionally (i.e. on parole supervision) and those released unconditionally, the Urban Institute found that those released unconditionally were no more likely to be rearrested than those with supervision conditions, after controlling for individual-level characteristics.114 Unconditional release paired with investment in community-based resources and reentry support mitigates many of these potential harms and allows people to successfully reenter their communities. ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• Conclusion: Closing women’s prisons in California is within reach “There should not be women’s prisons in this country at all. It is despicable that they are. Out of a hundred thousand incarcerated people, we’re looking at [less than] 5000 women. We don’t need to spend millions of dollars to incarcerate [less than] 5000 people. It is a waste of money, and it is ridiculous.” -Romarilyn Ralston, 58-year-old Black feminist, activist, and abolitionist, formerly incarcerated at California Institution for Women The evidence is clear: incarceration is harmful to health. Through isolation from families and communities, medical neglect and abuse, physical and emotional violence, toxic environmental conditions, and more, incarceration simply perpetuates a cycle of violence and trauma. But incarceration and the severe harms to individual and community health associated with carceral systems are not inevitable. In the last 12 years, California has seen a significant reduction — 70.8% — in the women’s prison population, resulting from policy changes and decarceration organizing efforts for decades before COVID-19 and beyond. The recent closure of the women’s units at Folsom State Prison is a positive step forward, and a comprehensive roadmap to decarcerate all women’s prisons would create more substantive outcomes. Change is within reach. HumanImpact.org/HealthNotWomensPrisons 34 Given the negative health consequences of incarceration, the costs of continued investment in carceral settings outweigh the benefits. 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