concerns. So perhaps it is not so surprising that prison and reentry policy makers have barely begun to recognize, let alone meet, the unique health needs of female prisoners and the formerly incarcerated in communities. Given the overwhelming numbers of women with serious health problems in custody, prison and reentry planners can no longer afford to ignore their needs. In fact, the numbers are startling. For example, women in prison are now more likely than men to be infected with HIV: 3.4 percent of female inmates are HIV positive compared to 2.1 percent of male inmates.20 The HIV infection rates among females are predominantly related to injecting drugs, crack use, and prostitution for drugs, which should give prison planners a starting point for counseling. Along with higher rates of HIV infection, women are at greater risk for sexually transmitted diseases that can have long-term implications for their overall health. Many women in prison also suffer from tuberculosis and various strains of hepatitis.
Apart from these chronic illnesses, women often have other health needs that go unattended as well. The Kaiser Family Foundation published information from its comprehensive 2001 Women’s Health Survey.21 In that important study, disparities in access to health care and the ability to receive treatment and services for women of color were detailed.22 One conclusion drawn from this literature suggests that if the physical problems women face as they are admitted to prison are not addressed while they are there, the problems are compounded when they are released into poor, urban communities.
According to the Women’s Health Data Book,23 nonfinancial factors —including the availability of needed health services in communities, transportation, child care, and the lack of culturally specific services—all combine with other factors to deprive low-income women of adequate health services. Lack of education, single-parent status, and access to—as well as utilization of—preventive health care services also play a significant role in the provision of health services to women of color.24 In addition to physical health problems, a number of studies suggest that women in custody also have higher rates of depression and other mental health problems.25 Often these mental health issues have not been diagnosed or treated. Women of color in custody are often victims of sexual and physical abuse. According to the United States Department of Justice, more than 50 percent of women in jail report that they have been the victims of physical or sexual abuse in the past, compared with 10 percent of men.26 Without intervention, these women are likely to return to their abusive relationships upon release.
Health problems can have a ripple effect in reentry planning and implementation. For women leaving prison with health problems, managing to engage in the behavior expected of a parolee may be difficult. They may experience difficulty keeping parole appointments. Quite obviously, health and mental health problems that remain unaddressed can interfere with anyone’s ability to obtain and maintain a job. When we add physical and mental health issues to the often overwhelming stress associated with regaining custody of children that they may have lost as a result of incarceration, the picture for women is even more troubling. It is this combination of health needs and the pressures of parental roles that weighs most heavily on the women ex-offenders and often guides their choices upon release—a factor too often ignored in examinations of the problems posed by reentry.
C. The Challenge of Motherhood behind Bars
Perhaps the most significant factor distinguishing women from their male counterparts relates to responsibility for their children. The average woman in prison had physical custody of a child before her incarceration. In the United States, approximately 2.1 percent of all children under the age of eighteen have parents in state or federal prison.27 This means that 1.5 million children are affected by the lack of any coherent reentry policy. The majority of mothers currently incarcerated were the sole caretakers for their children prior to incarceration. Generally, when a father goes to prison the mother keeps the family intact. However, a number of studies show that when a mother enters prison, the father often does not remain involved in the caretaking of the children. One study of state prisoners in the late 1980s found that 67.5 percent of the women had minor children as compared with only 54.4 percent of males.28 In 1986, “76% of women prisoners were mothers and nine out of ten of them had children younger than eighteen.”29 While “some children live with a relative during their mother’s incarceration, many enter the foster care system because no family member is available to care for them.”30 So for many women in custody or returning from incarceration the greatest challenge is reestablishing a relationship with their children. This fact has profound implications for women’s reentry programming.
One of the most punitive and detrimental effects of incarcerating women is the physical separation of mothers from children. There are few women’s prisons throughout the country. States generally have one or two women’s facilities, while the federal government maintains and operates relatively few institutions exclusively for women serving federal sentences.31 The limited number of institutions often means that women will be sent far away from their home communities and may often be housed in a separate state. A common side effect of this housing pattern is that women receive fewer visits from their children and family than men. Maintaining parental ties becomes all the more difficult. Children are often left to the care of the mother’s relatives or in the state’s foster care system when women are incarcerated. Consequently, women are often dependent on others to establish contact with their children. Women prisoners often must become accustomed to a lack of contact with their children.
As one would expect, the toll of this separation on mothers can be quite severe. Mothers commonly suffer from overwhelming anxiety and concern for their children. In many instances, the anxiety springs from the uncertainty of their children’s living situation. Mothers in custody have often made only temporary arrangements for their children. This instability of care arrangements becomes a continuing source of stress. Mothers in custody routinely report being overwhelmed by feelings of helplessness and hopelessness, which undoubtedly contribute to the higher incidences of clinical depression among women prisoners. This emotional and mental health toll can adversely affect the physical well-being of these women as well. Whatever the manifestation, the tremendous emotional burden that women carry is only complicated by the realization that they may ultimately lose custody of their children as they struggle to make sense of the legal system.
Physical and emotional separation from their mothers can cause severe emotional damage in children. Constancy and continuity of relationships, especially in the mother-child relationship, is essential for a child’s normal development during different life stages. Interruptions in those relationships can have a lasting impact on the child’s ability to bond with others. To the extent that infants and toddlers change—and must adjust to new—caretakers, they will often experience setbacks in their emotional development. Attachments, particularly at younger ages, are critical, and yet the imprisonment of their mothers often means that they will not have the benefit of constant, uninterrupted presence and attention from a familiar adult. When infants and young children find themselves abandoned by a parent, or shuffled between relatives, they may suffer separation distress and anxiety that will have long-term implications for their mental health.
The stress experienced by single mothers may be the most acute. They often risk termination of their parental rights simply due to the fact of their incarceration. A significant number of state prisoners find that following their admission to prison a court will place their children in the legal custody of others—often through the foster care system. In many instances these children enter the foster care system because no family member is available to care for them. When children are placed in the foster care system, the chances for permanent separation of mother and child become greater because it is more likely that a court will terminate the mother’s parental rights. Typically, once this has occurred, the mother will lose all rights related to her children and her children will be eligible for adoption—often without her knowledge or consent. Not only is there no guarantee that all the children awaiting adoption will be placed in adoptive homes, “but adoption does nothing to address the needs of poor families who are most at risk of involvement in the child welfare system.”32 This
