INCARCERATION and carceral status 101  

What are we talking about when we talk about incarceration, incarcerated patients and carceral status?  

Incarceration is the confinement of a person by the government, and can be used interchangeably with the term imprisonment [1]. Generally imprisonment refers to restricting a person’s liberty by placing them for a determinate time in a jail or prison as a penalty for a criminal offense [2].  Patients who are incarcerated can be confined to jails or prisons but may also include immigration detention centers, military prisons, or juvenile detention for children [3].  

Incarcerated patients include those who are charged with crimes and are awaiting trial and those who have been sentenced and are serving time in a prison or jail. Juvenile incarcerated patients are people under the age of 18; some may be charged with status offenses, which are infractions that only exist for children (i.e., running away, underage drinking, truancy from school) and presume that the child’s behavior is beyond parental control [4].  

The amount of time a person is sentenced to jail or prison varies based on whether the crime was a minor offense (misdemeanor) or a major offense (felony). Each state has its own criminal statutes that assign a range of sentences and punishments for each offense, including community service, fines, incarceration, and even death. Federal crimes are those where the U.S. government has asserted jurisdiction over the crime in the federal crime statute. Some Native American/American Indian tribes claim criminal jurisdiction over misdemeanor and felony crimes committed by Native Americans [5], and they may operate their own jail facilities or contract with other tribes, the state, or the Bureau of Indian Affairs to place members in carceral facilities [6].

Jails and prisons differ from each other and the terms are not used interchangeably. A jail is a local government detention facility for people who are awaiting trial, awaiting transfer to a prison or inpatient treatment facility, or have been sentenced to a short amount of time because the violation was a minor offense (misdemeanor). Other terms for jail include holding cell, correctional center, jailhouse, or lockup [7]. Prisons, in contrast, are facilities that are run by the state or federal government for people who have been sentenced to a crime. Incarcerated patients in a prison are more likely to have committed serious crimes (felonies). Some states contract with companies to run private prisons, wherein the administration and staff at the prison are employees of the company rather than a government agency. Other terms for prison include penitentiary, penal institution, and correctional facility [8]. 

Mass incarceration has severely impacted many communities across the United States, with 6.9 million adult admissions to jail in 2021 [9]. The data reveals that 1 in every 3 Black men and 1 in 6 Latinx men will be incarcerated at some point in their lives [10], women’s rates of incarceration in state prisons have increased 834% between 1978 and 2015 [11], and 19 U.S. states have disproportionate rates of Native American/American Indian inmates [12]. Incarceration is considered a social determinant of poor health due to the large numbers of people who are incarcerated living with serious medical issues and psychological trauma [13]; one study found that in the three months after their release from incarceration, returning citizens were 12 times more likely to die than the general population [14]. 

Why does carceral status matter in healthcare?

People who are incarcerated have higher rates of chronic illness and infectious diseases than the non-incarcerated population. Survey data collected by the U.S. Department of Justice in 2011-2012 found that an estimated 40% of people who were incarcerated, whether in federal or state prison or jail, reported having a current chronic medical condition and 50% reported ever having a chronic condition [15]. In comparison, 31% of the general population reports ever having a chronic condition. Chronic conditions for the purpose of this survey included diabetes, high blood pressure, stroke-related problems, heart-related problems, cancer, cirrhosis of the liver, asthma, and arthritis. Infectious disease rates were also high, with 21% of people in prison and 14% of people in jail reporting ever having tuberculosis, hepatitis B or C, or STIs excluding HIV/AIDS [15]. Hepatitis C was the most common infectious disease among people who were incarcerated, afflicting 10% of people in prisons and 6% of people in jail [15].

Despite presumptions that most diagnosis occurs when people enter the justice system, 73% of people in prisons and 77% of people in jails reported that their condition had been identified by a medical professional prior to their admission, and 61% of people in prisons and 59% of people in jails reported taking prescription medicine in the 30 days prior to their admission [15].  

Women and transgender males in the incarceral setting tend to be under age 45 and thus have specific reproductive health needs that should be routinely addressed. In one study, up to 40% of women who were incarcerated reported abnormal menstrual bleeding, and rates of breast and cervical cancers are higher for women who are incarcerated than those who are not [16]. 94% of women who are incarcerated report that they have experienced at least one physical or sexual act of violence during their lifetime [15]. In addition to reproductive health care needs, women who are incarcerated tend to be sicker than men, with 63% in state and federal prison and 67% in jails reporting ever having a chronic condition [17]. 

Correctional facilities are required to provide people who are incarcerated with adequate medical care [18]. When jail administrators “deny reasonable requests for medical treatment... and such denial exposes the inmate to ‘undue suffering or the threat of tangible residual injury’,” an inmate’s Eighth Amendment constitutional rights have been violated [19]. Medical care includes dental care and mental health treatment [20]. Many correctional facilities meet this mandate by conducting an initial medical screening within two-to-four hours of admission where they document healthcare history, current medications, recent and current communicable diseases, dietary restrictions and allergies, mental health history including suicidal ideations, substance use disorder or withdrawal symptoms, and pregnancy [21]. The Federal Bureau of Prisons maintains a Health Management Resources website that provides clinical guidelines for delivering health care in federal carceral settings [22]. Among their preventative guidelines are recommendations that all people who are incarcerated receive a baseline preventative care visit within six months of arriving in a federal incarceration facility in addition to receiving a health care screening at intake to address chronic conditions [23]. 

Health care professionals are often unfamiliar with working in carceral facilities or unsure of best practices for patients who are incarcerated. Carceral facility policies may be unclear, unknown, or incompatible with medical guidelines. Providers may confront unfamiliar issues such as shackling during medical exams or surgery [24], coordinating treatment plans and medications after a patient is released from incarceration [25], the presence of correctional staff during examination impeding the right to privacy [26], lack of advanced directives and health care proxies [27], and deep fear and distrust of medical providers who are seen as an extension of correctional staff [28].  

What do we know about carceral status in medical and health professions education? 

People who are incarcerated are guaranteed a right to adequate medical care in the United States as a protection against cruel and inhuman punishment. Despite this legal right, there are significant obstacles in obtaining adequate medical care. Medical educators should advance principles of health equity and justice by including in their curriculum education about health care access for patients who are incarcerated. 

A growing number of academic medical programs provide courses or incarceral clinic experiences in undergraduate and graduate medical education [13]. The curriculum varies in scope and duration, including 2-week clinical rotations, medical school electives, and clinical fellowship. Some incarceral health curricula may be integrated into an “underserved populations” elective or a rotation in family medicine. It does not appear that any medical education programs focus on obstetrics/gynecology, post-partum depression, breast health, menopause treatment, or prenatal/postnatal care for women or transgender men who are incarcerated. 

The content of medical incarceral curricula varies, but can cover addiction medicine, infectious disease, family medicine, orthopedics, transgender health, geriatric medicine, psychiatry, pharmacology, and public health. Additional skills that medical students learn through incarceral health care curricula are equitable health care delivery, learning to identify malingering, safety planning, working within bureaucratic institutions, collaboration between emergency departments and carceral facilities, continuity of care after release, and reducing bias and stigma [30].  Focus groups with current carceral healthcare providers suggested that a comprehensive incarceral health care curriculum should focus on six specific areas: demographics, common medical needs of the population, public health opportunities, ethical considerations, legal issues that impact health, and practical knowledge about the structure and administration of a correctional facility and health care center [31].  

Academic medical programs that provide training opportunities in incarceral settings emphasize that early exposure to people who are incarcerated increases empathy and influences students to choose careers in incarceral settings [32]. Studies have found that student placements in prison facilities help students become aware of prejudices and preconceived notions about people who are incarcerated, provide access to a marginalized and diverse population that students may not treat in other clinical situations, and teach students how to provide non-judgmental health care [33,34]. There remain questions about whether these benefits to learners are long-term, as none of the studies have been longitudinal in scope. 

A recent qualitative study exploring undergraduate medical student experiences at the only prison hospital in the United States (run by the University of Texas Medical Branch at Galveston) cautions medical educators to be thoughtful and deliberate in developing incarceral health care training opportunities.  Data collected from medical student focus groups found that medical learners who provided care in the prison hospital believed patients who were incarcerated were treated as second-class patients compared to patients who were not incarcerated, and pointed to bias issues in clinical decision-making and moralizing against patients who were incarcerated. Undergraduate medical educators should provide specific vulnerable population training for both medical learners and corrections staff; without a concerted training program that addressed these issues, the researchers believed the clinical prison experience would further exploit patients and exacerbate health inequity [34]. 

How does the Bias Checklist address carceral status in health professions education content? 

The Bias Checklist first asks:  

  • “Does the content include any discussion of incarceration or of the special healthcare needs of prisoners?” 

If you answer no, you will be prompted to consider whether your content should mention incarceration. 

Below are some examples of common ways in which bias, shame, stereotype and stigma toward incarcerated patients can manifest in health professions education content: 

  • Moralizing or assuming that people who are accused of criminal activities are deserving of their disease or illness 

  • Providing lack of equitable care, especially when compared to non-incarcerated patients, including spending less time in examination rooms or failing to take a full medical history 

  • Refusing to treat patients who are incarcerated in order to “protect” other patients 

  • Charging co-pays to patients who are incarcerated in order to dissuade them from seeking medical care 

  • Allowing structural issues that impact access to health care to stand rather than identifying and pointing out unjust and inequitable policies that undermine the physician’s ability to deliver equitable care and the patient’s ability to follow through [Example: knowing that prescription medications are not being provided to a patient upon release from incarceration and not intervening on behalf of a patient to address the issue] 

  • Failing to understand that many people accused of crime have been victimized and thus should be treated through a trauma-informed medical lens 

  • Using descriptors for patients such as “prostitute,” “criminal,” “addict,” “perpetrator,” “thug,” or “bad guy,” rather than person-centered language such as “patient,” “person who is incarcerated,” or simply, “person.”  

  • Blaming patients for non-compliance which may exist because of structural barriers to care instituted by the incarceral facility, particularly around medication, recovery instructions (e.g. keeping stitches out of water or sleeping on a bottom bunk), or dietary restrictions 

  • Failure to follow medical guidelines or deliver standards of care because “the incarcerated patient doesn’t care about their health” 

  • Assuming information (including health history, current medications, and post release health care providers) provided by the patient is inaccurate or the patient is trying to manipulate the staff 

  • Disregarding pain or physical complaints as malingering or teaching medical learners to start exams from a skeptical point-of-view 

  • Failing to provide a full medical exam or work-up because of handcuffs or other restraints 

  • Eroding the patient-doctor relationship by seeking unnecessary information (behavioral information, gossip, information about criminal past) from correctional staff 

  • Undermining patient privacy by sharing medical history or current treatment information with correctional staff above what they need to know to keep patients safe  

  • Using health care as punishment or failing to provide basic standards of care, including seeking informed consent and upholding maleficence, to patients because they “deserve” punishment 

  • Assuming that some exam questions are moot because the correctional facility prohibits certain behaviors, such as failing to inquire about drug or alcohol use, smoking, physical safety, or sexual activity during an examination 

  • Instructing receptionists and other staff to screen new patients about their criminal history or conduct background checks and including irrelevant information about prior criminal history in the medical chart 

  • Ignoring medical discharge plans from incarceral facilities and failing to integrate incarceral health care records into the current medical chart, because of a belief that medical care in incarceral facilities is of poor quality and should be disregarded 

Last, the Checklist asks:  

  • “Could the content be perceived as promoting stereotypes, bias, shame or stigma?” 

What can we do to address this problem? 

Check in soon: we will be uploading examples of health professions education content that show examples of bias related to carceral status and that show how content can be revised to address this subject in less biased ways. 

Where can I go to learn more?  

I learn best by…

Reading

 Watching 

Listening 

Need a consultation? 

The following people have identified themselves as experts in this domain and are willing to be contacted with questions regarding your content. 

  • Sarah Reckess, JD, Assistant Professor of Bioethics and Humanities, SUNY Upstate Medical University (reckesss@upstate.edu) 

Have something to add?  

Email us at biaschecklist@gmail.com with any of the following: 

  • Recommendations for additional important content to include above, or suggested corrections or clarifications → use the subject header “Incarceration 101 - Correction” 

  • Suggestions for additional resources for learning more → use the subject header “Incarceration 101 - Learn More” 

  • Examples of curricular bias, including before and after versions of content → use the subject header “Incarceration 101 - Example” 

  • Your name, credentials, affiliation, area(s) of expertise, and brief biography or summary of qualifications if you are willing to serve as an expert consultant → use the subject header “Incarceration 101 - Consultant” 

References 

  1. Garner BA, ed. Incarceration. In: Black's Law Dictionary. 8th ed. Thomson West; 2004:775.

  2. Cornell Law School Legal Information Institute. Imprison. Wex Legal Dictionary. Accessed January 20, 2023. https://www.law.cornell.edu/wex/imprison 

  3. Cornell Law School Legal Information Institute. Incarceration. Wex Legal Dictionary. Accessed January 20, 2023. https://www.law.cornell.edu/wex/incarceration 

  4. Garner BA, ed. Status Offense. In: Black's Law Dictionary. 8th ed. Thomson West; 2004:1112. 

  5. Garrow CE, Deer S. Tribal Criminal Law and Procedure. Altamira Press; 2004. 

  6. Jails in Indian country. Bureau of Justice Statistics, US Dept of Justice. Accessed February 12, 2023. https://bjs.ojp.gov/topics/tribal-crime-and-justice/jails-in-indian-country 

  7. Garner BA, ed. Jail. In: Black's Law Dictionary. 8th ed. Thomson West; 2004:851. 

  8. Garner BA, ed. Prison. In: Black's Law Dictionary. 8th ed. Thomson West; 2004:1232. 

  9. Zheng Z. Jail Inmates in 2021 - Statistical Tables. Bureau of Justice Statistics, Office of Justice Programs, US Dept of Justice; December 2022. 3. Accessed February 13, 2023. https://bjs.ojp.gov/sites/g/files/xyckuh236/files/media/document/ji21st.pdf 

  10. American Civil Liberties Union. Mass incarceration: an animated series. Accessed February 13, 2023. https://www.aclu.org/issues/smart-justice/mass-incarceration/mass-incarceration-animated-series 

  11. Sawyer W. The gender divide: tracking women’s state prison growth. Prison Policy Initiative. January 9, 2018. Accessed January 30, 2023. https://www.prisonpolicy.org/reports/women_overtime.html 

  12. Native Americans are incarcerated at the highest rate, new report reveals. Native News Online. January 10, 2023. Accessed February 12, 2023. https://nativenewsonline.net/currents/native-americans-are-incarcerated-at-the-highest-rate-new-report-reveals#:~:text=CHICAGO%20%E2%80%94%20A%20newly%20released%20report,higher%20than%20the%20national%20average 

  13. Min I, Schonberg D, Anderson M. (2012) A review of primary care training programs in correctional health for physicians. Teaching and Learning in Medicine. 2012; 24(1): 81-89. doi: 10.1080/10401334.2012.641492 

  14. Binswanger IA, Stern MF, Deyo RA, et al. Release from prison—A high risk of death for former inmates. N Engl J Med. 2007;356(2):157–165. doi: 10.1056/NEJMsa064115

  15. Maruschak LM, Berzofsky M, Unangst J. Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-12. Bureau of Justice Statistics, Office of Justice Programs, US Dept of Justice; 2015. Updated October 4, 2016. 1. Accessed February 13, 2023. https://bjs.ojp.gov/content/pub/pdf/mpsfpji1112.pdf 

  16. Maruschak LM, Berzofsky M, Unangst J. Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-12. Bureau of Justice Statistics, Office of Justice Programs, US Dept of Justice; 2015. Updated October 4, 2016. 2. Accessed February 13, 2023. https://bjs.ojp.gov/content/pub/pdf/mpsfpji1112.pdf 

  17. Maruschak LM, Berzofsky M, Unangst J. Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-12. Bureau of Justice Statistics, Office of Justice Programs, US Dept of Justice; 2015. Updated October 4, 2016. 1. Accessed February 13, 2023. https://bjs.ojp.gov/content/pub/pdf/mpsfpji1112.pdf 

  18. Maruschak LM, Berzofsky M, Unangst J. Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-12. Bureau of Justice Statistics, Office of Justice Programs, US Dept of Justice; 2015. Updated October 4, 2016. 5. Accessed February 13, 2023. https://bjs.ojp.gov/content/pub/pdf/mpsfpji1112.pdf 

  19. Maruschak LM, Berzofsky M, Unangst J. Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-12. Bureau of Justice Statistics, Office of Justice Programs, US Dept of Justice; 2015. Updated October 4, 2016. 10. Accessed February 13, 2023. https://bjs.ojp.gov/content/pub/pdf/mpsfpji1112.pdf 

  20. National Commission on Correctional Health Care Position Statement: Women’s health care in correctional settings. Adopted May 2020. Accessed March 5, 2023. https://www.ncchc.org/position-statements/womens-health-care-in-correctional-settings-2020/ 

  21. Browne A, Miller B, Maguin, E. Prevalence and severity of lifetime physical and sexual victimization among incarcerated women. International Journal of Law and Psychiatry. 1999; 22 (3-4): 301-322. doi: 10.1016/s0160-2527(99)00011-4 

  22. Maruschak LM, Berzofsky M, Unangst J. Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-12. Bureau of Justice Statistics, Office of Justice Programs, US Dept of Justice; 2015. Updated October 4, 2016. 5. Accessed February 13, 2023. https://bjs.ojp.gov/content/pub/pdf/mpsfpji1112.pdf 

  23. Estelle v Gamble, 429 US 97 (1976). 

  24. Monmouth County Corr Inst Inmates v Lanzaro, 834 F2d 326, 346 (3d Cir 1987). 

  25. Hoptowit v Ray, 682 F2d 1237, 1253 (9th Cir 1982). 

  26. Receiving Screening. National Commission on Correctional Health Care. Accessed February 20, 2023. https://www.ncchc.org/spotlight-on-the-standards/receiving-screening/ 

  27. Health Management Resources. Federal Bureau of Prisons. Accessed February 20, 2023. https://www.bop.gov/resources/health_care_mngmt.jsp 

  28. Federal Bureau of Prisons. Preventative Health Care Screening. Federal Bureau of Prisons Clinical Guidance. Updated July 2022. Accessed February 20, 2023. https://www.bop.gov/resources/pdfs/preventive_health_care_cg_2022.pdf 

  29. Scarlet S, Dreesen E. Surgery in shackles: what are surgeons’ obligations to incarcerated patients in the operating room? AMA Journal of Ethics Policy Forum. September 2017. Accessed February 20, 2023. https://journalofethics.ama-assn.org/article/surgery-shackles-what-are-surgeons-obligations-incarcerated-patients-operating-room/2017-09 

  30. Incarceration and health: A family medicine perspective. American Academy of Family Physicians. Accessed February 1, 2023. 

  31. McKinney EB. Hard time and health care: the squeeze on medicine behind bars. AMA Journal of Ethics. February 2008. Accessed on February 20, 2023. https://journalofethics.ama-assn.org/article/hard-time-and-health-care-squeeze-medicine-behind-bars/2008-02 

  32. Macleod A, Nair D, Ilbahar E, Sellars M, Nolte L. Identifying barriers and facilitators to implementing advance care planning in prisons: a rapid literature review. Health Justice. 2020; 8; 22. doi:10.1186/s40352-020-00123-5 

  33. Elumn JE, Keating L, Smoyer AB, Wang EA. Healthcare-induced trauma in correctional facilities: a qualitative exploration. Health Justice. 2021; 9 (14). doi:10.1186/s40352-021-00139-5 

  34. Min I, Schonberg D, Anderson M. A review of primary care training programs in correctional health for physicians. Teaching and Learning in Medicine. 2012; 24(1): 81-89. doi: 10.1080/10401334.2012.641492 

  35. Min I, Schonberg D, Anderson M. A review of primary care training programs in correctional health for physicians. Teaching and Learning in Medicine. 2012; 24(1): 81-89. doi: 10.1080/10401334.2012.641492 

  36. Min I, Schonberg D, Anderson M. A review of primary care training programs in correctional health for physicians. Teaching and Learning in Medicine. 2012; 24(1): 81-89. doi: 10.1080/10401334.2012.641492 

  37. Haley HL, Ferguson W, Brewer A, Hale J. Correctional health curriculum enhancement through focus groups. Teach. Learn. Med. 2009;21:310–317. doi: 10.1080/10401330903228513 

  38. Kjelsberg E, Skoglund, TH, Rustad A-B. Attitudes towards prisoners, as reported by prison inmates, prison employees and college students. BMC Public Health. 2007; 7(71). doi:10.1186/1471-2458-7-71 

  39. Filek H, Harris J, Koehn J, Oliffe J, Buxton J, Martin R. (2013). Students’ experience of prison health education during medical school. Med Teach. 2013; 35. doi:10.3109/0142159X.2013.827330 

  40. English M, Sanogo F, Trotzky-Sirr R, Schneberk T, Wilson ML, Riddell J. Medical students' knowledge and attitudes regarding justice-involved health. Healthcare. Sep 30 2021;9(10):1302. doi: 10.3390/healthcare9101302 

  41. Hashmi A, Bennett A, Tajuddin N, Hester R, Glenn J. Qualitative exploration of the medical learner’s journey into correctional health care at an academic medical center and its implications for medical education. Adv Health Sci Educ. 2021;26: 481-511. doi:10.1007/s10459-020-09997-4 

  42. Hashmi A, Bennett A, Tajuddin N, Hester R, Glenn J. Qualitative exploration of the medical learner’s journey into correctional health care at an academic medical center and its implications for medical education. Adv Health Sci Educ. 2021;26: 481-511. doi:10.1007/s10459-020-09997-4 

 Contributing Writer(s)

Sarah Reckess, JD

last updated June 15, 2023