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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

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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

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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.

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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.

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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
christine@humanimpact.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

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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.

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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

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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.

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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”).

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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

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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
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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

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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
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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

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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.

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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

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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

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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.

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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

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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%

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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
•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
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•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
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.
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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.

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