Women prisonersBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.e8318 (Published 11 January 2013) Cite this as: BMJ 2013;346:e8318
Women commit fewer crimes than men and make up only 5% of the total prison population.1 2 Nevertheless, their number has trebled over the past 20 years and there are now about 4000 female prisoners in England and Wales,3 an increase that outstrips that of the prison population as a whole (fig 1⇓).4 No evidence exists that women are committing more serious offences than before,5 and the rise is explained by a shift away from non-custodial penalties for relatively trivial offences towards short prison sentences.2 6
Different crimes, short sentences
The pattern of women’s offending differs from that of men. Women have a lower involvement in serious violence, criminal damage, and professional crime5 but commit proportionally more acquisitive crimes such as theft.7 Women’s crimes are likely to be related to their domestic situation,5 8 with crimes being committed to provide for families or to fund a woman’s or her partner’s addiction.8
Half of women prisoners serve sentences of six months or less (fig 2⇓).2 This gives rise to a rapid turnover in the female prison population. The number of women committed to prison each year far exceeds the level of the female prison population at any one time. During the year ending July 2011 there were about 4 200 9 women prisoners in England and Wales at any one time, but 10 173 women were received into prison.10 Nearly half of women entering prison are on remand,2 and after an average prison stay of four to six weeks, over half of remanded women do not receive a custodial sentence.11 Within one year of leaving prison 51% of women are reconvicted.2
Women’s experience of prison
British prisons were built for men and are predominantly managed by men.12 There are both female and male staff in women’s prisons, but the prison inspectorate in England and Wales consistently reports the ratio of male to female staff as too high.12 Women’s prisons adhere to security regimes designed for men.5 This may be inappropriate as women do not pose the same risk of escape and are unlikely to riot.5
There are 13 women’s prisons in England, none in Wales,2 and one in Scotland.32 Women prisoners are also held in five predominantly male prisons, where they are housed on separate wings. The small number of women’s prisons results in a wide mix of prisoners; young adults, mothers and babies, and remand, short sentence, intermediate sentence, and long sentence prisoners can all be housed under the same roof. 13 It also means that female offenders are often held further away from their families than men.5 In 2004 women were held on average 62 miles away from their homes, in comparison with 51 miles for men.5 In 2009, 753 women were held over 100 miles from home.14
It is argued that women find prison more distressing than men and suffer disproportionately.15 At least a third of women are lone parents before imprisonment,5 and prison takes women away from their families, where they are likely to have had a central role.5 The distress of female prisoners may also be explained by the vulnerable nature of the women that courts are imprisoning. Women in prison are likely to experience multiple health and social needs.16 One in four has spent time in local authority care as a child, half say they have suffered domestic violence, and a third say they have experienced sexual abuse.17
High risk of self harm and suicide
Studies suggest that up to 80% of women in prison meet diagnostic criteria for mental disorder,17 18 and a third of women prisoners have attempted suicide before imprisonment.17 Once in prison self harm is common, with 16% of women self harming compared with 3% of men.5
Despite only 5% of prisoners being female, women account for 47% 2 of all incidents of self harm in prison (fig 3⇓). Women prisoners also have a much higher rate of suicide than male prisoners or women in the community.19
Female suicides in prisons in England and Wales reached a high of 14 in 2003.20 By contrast one suicide was recorded in 2011.21 Increased awareness of prison staff and management of self harm and suicide has helped reduce suicides, and the introduction of the Assessment, Care in Custody and Teamwork protocol22 in 2007, aimed at identifying and supporting prisoners at high risk of suicide, may also be a factor.
Poor self reported health
Women entering prison tend to rate their physical health as poor,23 and their level of contact with community health services before imprisonment is below average.23 Although the prison inspectorate reports that health services for women in prison are improving, quality varies.13 Services face the challenge of providing “compensatory care” to women whose health needs have not been met in the community.23 These needs are often complex and difficult to address during short sentences.23
Many women also have longstanding drug and alcohol problems. In one survey 52% of women said that they had used heroin, crack, or cocaine powder in the four weeks before custody, compared with 40% of men.24 The prisons inspectorate found in 2010 that 29% of women had an alcohol problem on arrival in prison, compared with 19% of prisoners as a whole. This means women are disproportionately affected by the underdevelopment of treatment for alcohol problems in prison.25
The health of women who used drugs in the community may improve in prison, perhaps because prison offers health benefits such as regular meals, protection from violent relationships, and access to health services.23 Little change is reported in women with no history of drug use.23 On release, ongoing care is often restricted to a summary letter to the prisoner’s general practitioner, with limited help provided for women without a GP.13
Uncertainty surrounds the number of pregnant women in prison. Not every woman will choose to have a pregnancy test, and some women may pass through prison without their pregnancies being recorded.26 In England and Wales about 600 women prisoners receive antenatal care each year.27 About 170 imprisoned women will give birth each year27; except in emergencies, births take place in a local NHS hospital.28 29 Women may be shackled during the early stage of labour as well as on hospital visits.28 Channel 4 News highlighted shackling of prisoners during childbirth in 1996, and the issue was discussed in parliament.30 31 One prison governor told me that shackling during labour is now “extremely unlikely” but is not actually forbidden.
Some women will receive better care in prison than similarly disadvantaged women in the community. However, taken as a whole, prison perinatal care is variable.26 One problem is that prison officers are often unavailable as escorts and outpatient appointments may be cancelled at the last minute, making it difficult to ensure that scans or other investigations happen on time.28 Prisoner relocation or release at short notice can also compromise the quality of the service.28
After delivery, some babies are cared for by the prisoner in mother and baby units; others go to relatives or are fostered. Secure mother and baby units in England and Wales have the capacity for 77 women.32 Prison mother and baby units are unlike those in the community, which offer treatment to mothers who have a serious mental health problem such as puerperal psychosis. Prison units exist to provide a suitable environment for the care and development of babies and young children whose mothers are imprisoned.26 A mother with mental ill health is unlikely to be offered a place.26
Mother and baby units in prison are argued to be in the best interests of the child, as they allow bonding to occur between mother and child in the first year of a child’s life.33 However, prisons are not an ideal environment for a developing child as they lack stimuli,34 and separation of mother and child is inevitable when the mother is serving a long sentence.33
Recommendations on reducing numbers have not been implemented
A series of independent and government reviews on women’s imprisonment in the UK have been published since 2000.5 8 16 34 35 These reports come to a similar conclusion: there is a strong case for reducing the imprisonment of women.36 It seems that for many women prison serves little purpose except to disrupt sometimes already chaotic lives.
In 2007 the Home Office commissioned Corston report proposed an approach tailored to women offenders’ needs and with visible senior leadership for England and Wales.5 It recommended the closure of large women’s prisons and replacement with smaller geographically dispersed custodial centres, and the establishment of local community centres for women offenders. These local women’s centres are to supervise community sentences and act as a “one stop shop,” building relationships with health, social care, and criminal justice agencies and encouraging women to access early support and intervention. In Scotland the Commission on Women’s Justice report in 2012 made similar proposals.37
Corston’s recommendations were intended as a coherent strategy. However, in common with the reviews that preceded it, the government did not accept the recommendations in full.38 39 The closure of large women’s prisons was rejected.40 Visible senior leadership is not in place,12 40 and although successful women’s centres are now established, their funding is not secure.12 40 41 In the five years since the report was published the number of women in Britain’s prisons has not fallen substantially.12 The argument that the needs of women prisoners are different from those of men is yet to be won.42
Cite this as: BMJ 2013;346:e8318
This is the fourth in a series of articles examining the challenges of looking after prisoners’ health
I thank the following people for help with this series: Louis Appleby, national director for health and criminal justice; Annie Bartlett, clinical academic and clinical director; Michelle Baybutt, programme lead, Health, Inclusion & Citizenship, Lancashire University; Marcus Bicknell, chair, Royal College of General Practitioners secure environments group; Luke Birmingham, consultant forensic psychiatrist, Southern Health NHS Foundation Trust; Rex Bloomstein, documentary filmmaker; Richard Byng, senior clinical academic in primary care, Institute of Health Service Research, Peninsula College of Medicine and Dentistry; Clive Chatterton, former prison governor, HMP Styal; Angela Clay, chairman, Association of Members of Independent Monitoring Boards; Sally Cottrell, head of evaluation, Avon Primary Care Research; Andrew Coyle, former director, International Centre for Prison Studies; Graham Durcan, associate director, Criminal Justice Programme; Dawn Edge, research fellow, University of Manchester; Tim Exworthy, consultant forensic psychiatrist, St Andrew’s Hospital; Helen Fair, research associate, International Centre for Prison Studies; Michael Farrell, director, National Drug and Alcohol Research Centre; Seena Fazel, clinical senior lecturer, Department of Psychiatry, University of Oxford; Andrew Forrester, honorary senior lecturer in forensic psychiatry, South London and the Maudsley NHS Trust; Andrew Fraser, director of health and care, Scottish Prison Service; Claire Gauge, head of learning lessons, Prisons and Probation Ombudsman England and Wales; Paul Hayton, deputy director, WHO (Europe), Collaborating Centre for Health and Prisons; Alex Hewson, policy and programmes manager, Prison Reform Trust; Adarsh Kaul, clinical director, Offender Health, Nottinghamshire Healthcare NHS Trust; Annabel Kennedy, director, Birth Companions; Richard Knowles, head of prison healthcare, NHS Isle of Wight; Nick Le Mesurier, independent researcher and honorary lecturer, Staffordshire University; Jonathan Lloyd, GP, HMP Nottingham; Juliet Lyon, director, Prison Reform Trust; Eoin McLennan-Murray, president, Prison Governors; Natalie Mann, lecturer in criminology, Anglia Ruskin University; Ryan Mullally foundation year 2 trainee, Nottingham University Hospitals; Nigel Newcomen, prisons and probation ombudsman, England and Wales; Éamonn O’Moore, consultant in public health, Offender Health; Frankie Owens, former prisoner; Mary Piper, senior public health consultant, Offender Health; Emma Plugge, department of public health, Oxford University; John Podmore, former prison governor, HMP Brixton; Lord David Ramsbotham, former HM inspector of prisons; David Scott, senior lecturer in criminology and criminal justice, University of Central Lancashire; Toby Seddon, professor, School of Law, Manchester University; Joe Sim, professor, School of Humanities and Social Science, Liverpool John Moore University; Nicola Singleton, Director of Policy & Research UK Drug Policy Commission; Richard Smith, former editor, BMJ; Alastair Storey, clinical lead and manager Find&Treat; Elizabeth Tysoe, head of healthcare inspection, HM Inspectorate of Prisons; Azrini Wahidin, reader in criminology and criminal justice Queen’s University Belfast; Stuart Ware, founder of Restore Support Network; Susan Yates, research nurse, Royal Free Hospital; the staff and governor of HMP Nottingham; the staff and governor of HMP Isle of Wight.
Contributors and sources: SG is an ST5 trainee in general adult psychiatry and was the 2011-12 Roger Robinson BMJ editorial registrar. Information for this series was obtained from an unsystematic literature review, prison visits, and discussions with prison doctors, prison nurses, prison and forensic psychiatrists, prison governors, prison reformers, prison health managers, prisoners, criminologists, sociologists, and prison inspectors.
Competing interests: The author has completed the ICMJE unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.