By Michelle Staples Horne, MD, MPH, CCHP
Posted on June 13, 2008 – The provision of health care to female adolescents in an incarcerated environment presents a challenge to health care providers, as well as to administration and security staff. Why is it so difficult to provide services to this population? There are many reasons. I will try to address a few that I feel significantly impact our service delivery.
Females in general have a higher utilization of medical care while in the community. The greater prevalence of chronic diseases, including mental health diagnoses and the provision of prenatal care and delivery, also tend to accelerate utilization and expenditures for female juvenile facilities. Greater health care expenses should always be anticipated in providing health services to females in a juvenile facility as compared to males. Medicaid exclusions for the provision of health care to incarcerated youth, as well as most incarcerated youth being uninsured, can create a financial burden on facilities and correctional agencies in the provision of quality health care. Despite financial constraints, the community standard of care must be maintained, if not exceeded, in this medically underserved population that has a constitutional right to health care while incarcerated.
In most cases, girls were victims of physical and sexual abuse before they became offenders. Internalization of feelings associated with this abuse may present as self-harm through prostitution, substance abuse, eating disorders, self-mutilation or other self-harm behaviors. Other internalizing disorders may manifest themselves as depression and/or anxiety disorders. Some will even lash out violently at the perpetrator or others as a result of the abuse with aggression, conduct disorder, oppositional or defiant behavior, resulting in their entry into our system. Girls are three times as likely to have been sexually abused as boys. In some detention facilities, the incidence of girls who have been abused is close to 90%. Most are victims of family members or close family friends who are perceived as trusted adults. This explains why they often mistrust even the medical staff and do not easily disclose pertinent history. Additionally, girls are even more likely to have been physically abused. A considerable body of literature has firmly established the relationship of adolescents’ reports of physical and sexual abuse with multiple forms of subsequent mental illness.
A history of traumatic stress may lead to a definitive diagnosis of Post-Traumatic Stress Disorder (PTSD) or at least interfere with her ability to learn and function appropriately in society. We tend not to routinely screen girls for trauma including physical and sexual assault, illness and injury relating to abuse, or witnessing violence. These traumatic events can trigger behavioral health disorders. Female juvenile offenders are considerably more likely to have mental health conditions such as major depression and bipolar disorder. Often comorbidity exists with mental illness and substance abuse. It is difficult to know which disorder preceded the other and whether the substance use is for the purpose of self-medication. Failure to screen and identify these conditions for treatment may result in these problems becoming manifest or progressively intensifying during periods of incarceration. A female offender’s history of victimization may make compliance with simple medical regimes an issue. Emotional liability may trigger somatic responses such as a herpes outbreak or gastrointestinal upset. They may demonstrate unacceptable behaviors toward medical staff even when presenting with a medical complaint. Sometimes these behaviors lead to the perception by staff that the offender is being manipulative or feigning illness. All staff should be trained to take all medical complaints seriously and respond appropriately.
Pregnancy represents an additional health issue, unique to female offenders, that adds to the challenge of health care while incarcerated. Adolescent pregnancies in general are high-risk, often requiring specialized obstetrical care. Often, young female offenders will present to the facility with limited or no prenatal care along with a multitude of high-risk behaviors including substance use, sexually transmitted infections and trauma histories. Management of these issues requires attention to adolescents’ current needs (e.g., prenatal and postpartum care) and future needs (e.g., avoiding repeat pregnancy, contraceptive information, development of parenting skills). These programs may be most effective if they address multiple aspects of the female adolescent’s life, including potential motivations to purposefully conceive.
Providing health services to female juvenile offenders requires an interdisciplinary approach to staffing and program development. Of course, the inclusion of licensed health professionals is important in staffing a juvenile correctional facility, but correctional staff must also be well trained and receive educational programs relating to medical needs specific to the population served. Staffing patterns and ratios at female facilities should reflect the increased utilization of health services by female juvenile offenders. Medical staff should be aware of the health problems more likely to affect girls of color, who are disproportionately represented in the juvenile justice system. Cultural sensitivity on the part of medical, administrative and security staff is mandatory and should go beyond just creating cultural diversity through the staff hiring. It truly takes a village to serve female adolescent offenders.
The vast majority of female juvenile offenders have been underserved by their families, schools, and communities. Indeed, periods of incarceration may often comprise the only opportunity these adolescents have for the receipt of medical and dental care and preventive services. The detention and incarceration period also offers the opportunity to present disease prevention and health promotion messages to female offenders engaging in high-risk behaviors. Gender-specific prevention and treatment programs, tailored to the unique needs of female juvenile offenders, constitute an essential starting point for addressing these missed opportunities. Indeed, the Juvenile Justice and Delinquency Prevention Act specifies that programs should be established that meet the full range of health needs (e.g., mental health, substance abuse, physical and sexual assault) experienced by female offenders.
Despite the challenges observed, the opportunity exists, during the detention and incarceration period, to provide female offenders with effective programs including comprehensive health services, promoting physical and mental wellness, good nutrition, exercise, reproductive health, disease prevention, and stress management. Other health education programs should address smoking, alcohol and drug use, with resources for treatment programs available. Behavioral management programs are essential since most juvenile offenders have difficulties with anger management and nonviolent conflict resolution.
After all, these required increased resources are well spent on a female juvenile offender. They multiply exponentially in the potential benefit not only of the girl’s individual health, but the opportunity to impact the lives of her children and break the family cycle of incarceration.
SCP President Michelle Staples-Horne is the Medical Director of the Georgia Department of Juvenile Justice. Readers may contact her at horne@djj.state.ga.us.
