Understanding incarcerated populations

Cheryl L. Cooke

In the United States approximately 1.3 to 1.8 million people are incarcerated in state or federal prisons or local jails at any given time. (1) Approximately 682 people per 100,000 are incarcerated, and during the 1990s, the growth rate was approximately 6% annually. (2) It was estimated that the United States would have two million people incarcerated by the end of 2001. (3) Approximately 6.3 million people, or 3.1% of the country's adult population, are under some form of correctional control, either through probation or incarceration in a state or federal prison or a local jail. (4)

Nurses may come in contact with people who are under some form of correctional control in many health care settings (eg, hospitals, outpatient settings, corrections systems, clinics). Nurses must educate themselves about this patient population to provide safe, effective health care to these patients.

DEFINITION OF TERMS

In conversations about incarceration, the terms jail and prison often are confused. Jails and prisons, however, are different types of facilities. Jails house people who are awaiting the disposition of their case or transfer to another facility and those who have been convicted and will be incarcerated for less than one year. Jails often are located in urban settings within the city limits, and they provide housing for people of varying custody levels. For example, when incarcerated, jail inmates are held in one facility regardless of their crime or perceived degree of dangerousness. They may be housed in different sections of the facility for security reasons, with those inmates perceived to be more dangerous than others being closely supervised. Jails provide many types of health care services (eg, sick call, ongoing treatment for chronic illnesses, limited prenatal care). Jails usually are located in close proximity to major trauma centers because of their urban settings.

Prisons, however, provide housing for people who have been convicted and sentenced to serve 366 days or more. Prisons usually are located in remote regions and may house prisoners of various custody levels. In prison, custody level is determined at a reception center, and inmates are sent to the appropriate facility based on their need for supervision or perceived degree of dangerousness. Prisons are federal, state, or privately run facilities. (5)

CHARACTERISTICS OF PATIENTS WHO ARE INCARCERATED

Of those people currently incarcerated, approximately 90% are male. Between 54% and 59% of all jail and prison inmates have a high school diploma. An estimated 4% to 8% of individuals who are incarcerated are not US citizens. More than one-third of jail inmates have some sort of physical or mental disability. (6)

Individuals may be in custody or under correctional control in a variety of ways (eg, in prison or jail, on probation, performing community service, participating in a drug diversion program). Others may be incarcerated in long-term mental health facilities as a result of their crime. Estimates are that between 10% and 25% of all people who are incarcerated at any one time are diagnosed as mentally ill. (7)

Women make up an ever-increasing portion of the prison population. In 1998, approximately 3.2 million women were arrested, accounting for approximately 22% of all arrests that year. During that same year, approximately 1% of all women in the United States were under some form of correctional control. In 1996, women in jail comprised between 5% and 10% of the jail population. They most frequently are incarcerated for nonviolent, drug-related offenses. Approximately 50% of women in jail report experiencing physical or sexual abuse before incarceration; 27% report being raped. (8) Between 1997 and 1999, more than 1,300 babies were born to mothers in custody in US prisons or jails. (9)

Incarceration and the war on drugs. The war on drugs consists of a series of economic and regulatory policies that have resulted in an influx of people into jails and prisons with subsequent billions of dollars spent supporting the criminal justice system in the United States. The "prison industrial complex," a term coined by Angela Davis, PhD, addresses how these policy initiatives are approached in the same manner as the military was built during the 1950s and 1960s. (10)

The total number of people sentenced in the United States between 1985 and 1995 increased 84%. Of this increase, 52% is attributable to sentences related to drug crimes. During this 10-year period, there was a 331% increase in drug sentences, with the number of people sentenced for drug-related crimes increasing from 24,200 to 104,400. (11) The war on drugs has resulted in an incarceration rate of more than 70% for nonviolent offenders, many of which may be amenable to treatment instead of nonrehabilitative confinement.

Recent data on crime and drug use show that 51% of all convicted inmates state they were under the influence of illegal drugs or alcohol at the time of their offense. Eighty-three percent of state prisoners admit to using drugs at some point in the past, and 57% say that they used drugs within one month of committing the offense for which they are incarcerated. Of those incarcerated, more than one-third of state prisoners admit that they committed their current offense while under the influence of drugs. (12) Mentally ill offenders report the highest rates of drug use at the time of incarceration, with 60% to 65% of prison and jail inmates with mental illness reporting illegal drug use. (13) Drug use is a factor in the lives of people before incarceration and may be an instrumental reason why crimes such as theft, larceny, and forgery are committed.

Incarceration and its effects on communities of color. Most of the people incarcerated in the United States are people of color, and the majority of these individuals are men and are either Hispanic or African American. On June 30, 2000, approximately 12% of all African American men in their twenties and early thirties were incarcerated. This compares to 4% of Hispanic males and 1.7 % of Caucasian males. Of the total number of men incarcerated on that date in federal or state prisons or local jails, almost 800,000 were African American men of non-Hispanic origin, making up approximately 45% of the total prison population. (14) In Washington, DC, and Baltimore, 1991 estimates show that between 42% and 56% of the African American male population between the ages of 18 and 35 was under some form of correctional control. (15) The number of men of color who are incarcerated increased significantly after the initiation of the war on drugs and the changes made to the US drug and sentencing policy, which was enacted in the mid-1980s.

It is important to note that people of color are not committing a significantly greater number of crimes. They are, however, incarcerated more frequently for the crimes they commit. (16) One author states that between 44% and 47% of arrests for violent crimes are of African American men, compared with arrest rates for violent crimes of Caucasian men of 50% to 54%. (17) Another author suggests that although high at 45%, the percentage of arrests of African American men for violent offenses (eg, murder, aggravated assault, robbery, rape) has remained relatively stable during the past 10 years, with a downward trend. (18) It is not that African American men are committing an increasing number of crimes but that disproportionate punishment for African Americans has worsened. (19)

Much of the disparity in who goes to prison and who does not can be explained by significant differences in drug sentencing policies. One example is what happens when a person is convicted of possessing cocaine. Possession of crack cocaine, a crystallized form of powder cocaine, carries a far greater penalty than does possession of up to five times the amount of powder cocaine. This disparity benefits those who are able to afford the more expensive drug (ie, powder cocaine) with a lower risk of incarceration. Data from 1993 show that up to 88% of all inmates incarcerated for cocaine violations in federal prisons were African American. (20)

Incarceration and its effects on families. The loss of a male family member to incarceration is likely to have psychological, developmental, and behavioral effects on the children of men who are incarcerated. (21) Data from 1997 show that there are 1.5 million children with a parent who currently is incarcerated, with estimates of up to 10 million children younger than age 18 who have a parent who was incarcerated in the past. (22) Children whose parents are incarcerated make up some of the "most at-risk, yet least visible" populations. (23) Ninety percent of children of men who are incarcerated remain in the custody of their biological mothers during their father's incarceration. (24)

Many prisons are located in rural settings, and family members of people who are incarcerated must cope with the challenge of maintaining a relationship with their incarcerated family member. Often, people who are serving long sentences may discourage family member contact due to the difficulty of maintaining a relationship or the hardship of travel to and from the prison.

The effects of disproportionate incarceration on families. One of the effects of the disproportionate incarceration of men of color is disruption of family relations and functioning and its effect on children in the family. Although incarceration disrupts most families, the number of incarcerated Caucasian men reflects their number in the population (ie, 36%). (25) For African Americans with a disproportionately high number of men (45%) removed from the family through incarceration, (26) family members are at greater risk for poverty, school failure, and behavioral, physical, and emotional problems. Negative effects on unemployment stability, family life, alterations in the life chances of children of incarcerated African American men, and an overall effect on community functioning complicate the disruption. (27)

Ongoing issues with institutionalized and internalized racism contribute to the problems faced by African American families. African American men and their family members must deal with incarceration in a system that is administered by and where policy is set predominately by Caucasian men and women (eg, attorneys, judges, corrections officers and officials). This poses a greater risk of African American men and their family members getting caught up in a system that rarely recognizes specific aspects of their cases from important historical, political, and social perspectives. (28)

ASSUMPTIONS ABOUT PEOPLE WHO ARE INCARCERATED

People who are incarcerated may seek health care services infrequently and often suffer from chronic physical or mental health problems. They may be distrustful of health care personnel. This distrust is warranted because prisoners have been subjected to cruel and often harmful experimentation in the name of advancing medical science. (29) It is important to identify where health care workers' understanding comes from regarding who deserves care and how that care should be provided. Understanding where ideas regarding care provision develop, are supported, or discouraged can be instrumental in limiting or eliminating deferential or less than empathetic care.

One author states that some women who are incarcerated believe that they receive nonempathetic treatment or that their symptoms are disregarded by health care providers. (30) Some report that health care providers say that all prisoners are drug seekers, complainers, or deserve what illnesses or symptoms they have. (31) One nursing role is to do no harm, and nurses need to understand how assumptions, fears, and stereotypes can hinder the provision of quality, compassionate care.

Perceived dangerousness, incarceration, and health care provision. Approximately 45% of people who are incarcerated are in custody for violent offenses. (32) Arbitrary and stereotypical labels such as "dangerous" may be given to incarcerated individuals who resist prison policies, such as being cuffed for transfer and performing personal hygiene, and to those who act out against corrections personnel or other inmates or those whose resistance may be triggered by mental illness. Unfortunately, the idea that people are in prison because they are dangerous is reproduced in nightly news accounts, movies, and television shows, such as COPS, America's Most Wanted, and NYPD Blue.

The public, health care providers, and members of the criminal justice community sometimes casually use labels such as "psychopath" or "sociopath" when talking about people who are incarcerated. One author asserts that terms like these often are reserved for minorities in custody who are least likely to be able to afford less destructive diagnoses. (33) Many African American family members are reluctant to participate in the mental health system as a result of

* historical injustices,

* costly services,

* decreased insurance coverage or lack of coverage, or

* ongoing feelings of distrust of the system related to historical medical racism (eg, the Tuskegee Syphilis Study) or the paucity of mental health care providers who understand the particular concerns of African Americans.

African American boys often are labeled in early life with destructive psychiatric diagnoses such as "conduct disorder," a behavioral diagnosis that often is translated later in life to "antisocial personality disorder," a more serious diagnosis that can be anxiety producing for those working in the criminal justice or mental health systems. If parity in mental health care services existed, African American children might be able to avoid such diagnoses through appropriate mental health care assessment and treatment, thus lessening the chance of receiving labels that can be interpreted negatively within the criminal justice system.

This same author also suggests that young African American men receive Diagnostic and Statistical Manual of Mental Disorders diagnoses of conduct and personality disorder with alarming regularity. (34) This manual is used by mental health care providers to diagnose psychiatric illnesses. These diagnoses often affect the treatment of African American men while they are incarcerated. Those diagnosed with mental disorders may be considered "dangerous" regardless of their actual behavior while in prison or jail because of the criteria for such diagnoses. These diagnoses often are made at an early age, frequently through interactions in the school system. (35)

Stereotypical and negative media representations of minority youth, particularly African American young men, enhance the meaning of these medical diagnoses, increasing the likelihood that minority youths' experiences in the criminal justice system will be more complex. The experiences of incarcerated African American youth and men are complex because of labeling. When negative media representations are added to the picture, the experiences of African American men become even more complex. It becomes difficult to overcome such representations in the minds of people who believe they are accurate portrayals of African American youth and men. An example of negative media representation can be found in the case of Susan Smith, the South Carolina mother who accused an African American man of car-jacking her car with her children inside, when, in fact, it was she who murdered her children by drowning them in a local lake. These types of representations complicate an already challenging picture for African American men by increasing the perception that they are dangerous. Being labeled dangerous does not accurately reflect their behavior after entering the criminal justice system, but a label of "dangerous" influences how they are processed through the system. (36)

The concept of perceived dangerousness can be described using the body as an example. The body of a person who has been incarcerated often reflects the challenges of living in a difficult environment. Many inmates' bodies have a series of tattoos that may be perceived by others as violent or offensive, and insignias may be present on any number of body parts that may reflect gang involvement, artistic ability, or other significant meaning. To the inmate, tattoos often are a symbol of acceptance or a source of pride. These tattoos, however, may be offensive to health care providers, at times evoking feelings of fear or disgust.

Awareness of the inclination to label incarcerated people as dangerous based on looks, perception, and media accounts may be important for health care workers to understand the challenges in providing patient care services to this population. It remains important for nurses to remember that their first responsibility is to provide essential and supportive patient care.

CARING FOR PEOPLE WHO ARE INCARCERATED

In most prisons, health care services usually are provided by various practitioners (eg, advanced RN practitioners, licensed practical nurses, licensed vocational nurses, physicians, physician assistants, RNs). Care usually consists of the prisoner sending a note to the nurse and being triaged into an appointment, sometimes several days later. Prisoners often are transferred to a larger, more complex health care facility to receive treatment for major injuries or illnesses and for childbirth. Both emergency and some elective procedures are performed at off-site health care facilities. Corrections personnel accompany prisoners during transfer to such facilities.

When caring for an incarcerated patient, it is important that the patient and nurse thoroughly understand the nursing role. One aspect of the nursing role is patient confidentiality. For example, nurses may be curious about or ask for information regarding an inmate's crime or sentence. Inmates often are not willing to share this information with people not connected to the corrections system. This information is private and having it may interfere with the nurse's ability to provide quality patient care.

At times, evidence in the form of secretions, hair, or other body fluids or materials will need to be collected to support a criminal proceeding. The nurse must remember that his or her role is that of health care provider. In that capacity, he or she is not an agent of the criminal justice system. In most settings, nurses do not collect evidence; however, a patient who is incarcerated may fear that this is part of the nurse's role. It is important to clarify the nursing role to incarcerated patients and assure them that nurses are not part of the legal team and will not collect physical evidence. Knowing this may help the patient feel more comfortable receiving care.

As previously discussed, the perception that an incarcerated person is dangerous may be common among providers who are not familiar with this population. Corrections personnel will accompany the patient to the health care facility, and their presence may contribute to this perception. Corrections personnel may be corrections officers from federal or state prisons, local police officers, or county sheriff personnel, depending on the custody setting in which the inmate resides. These officers must adhere to specific policies when accompanying an inmate outside of the corrections facility. Custody policies vary according to setting and may be at odds with the mission and policies of the health care facility providing services. There often are tensions between those individuals who provide health care services and those who provide custody services.

Confinement and the use of shackles. One consideration when caring for a patient who is incarcerated is the possibility of escape. The patient may be handcuffed or shackled with a set of manacles that are cuffed with a chain linking the ankles. The patient often remains in a locked room with a guard posted outside. At times, the patient may be restrained to the bed or stretcher.

The use of shackles or other restraint systems, at times, has been a source of contention between health care workers and corrections personnel. Perioperative personnel have particularly important concerns related to the use of shackles because metal shackles interfere with the grounding of electrical equipment used during surgical procedures and can increase the risk of injury. Many facilities have specific policies regarding the use of shackles and restraints. Those policies may require that shackles be removed and the facility's restraint system be used to reduce the possibility of injury to the patient in the event of an emergency (eg, fire). In an emergency in which corrections personnel may not be available, nursing staff members must be able to remove the restraints and move the patient to a safe location. Policies regarding how restraints will be applied and managed must be developed before receiving a patient who is in custody. Restraints must be checked frequently to preserve skin integrity.

One nursing role is to maintain patient safety. If someone is shackled in a manner that is detrimental to the procedure, the need to reposition and/or remove the shackles should be explained to corrections personnel. Often, corrections personnel may need to be educated about patient safety. For example, it may be necessary to explain that it is uncommon for a patient to escape while receiving sedation or anesthesia. If an incarcerated patient is expected in the OR, it is important to review facility policies before his or her arrival. It may be more stressful and challenging to negotiate restraint use with corrections personnel after the patient is admitted. If the conflict is unresolved, it may be necessary for hospital administrators to contact the supervisor of corrections personnel for resolution.

Some disease processes and related care issues in the prison setting. Incarcerated populations have HIV and AIDS rates seven times that of the general population. (37) The transmission of HIV, AIDS, and hepatitis C can be associated with drug use or prostitution. Many prisoners have a history of drug use, and many have a history of prostitution to support their drug habit. Universal precautions are a standard of care in ORs and other settings where surgical interventions are provided, and maintaining universal precautions with individuals who are incarcerated will help protect nurses and other health care providers from blood-borne illnesses. Prisoners also may suffer from a variety of other chronic diseases, such as diabetes, tuberculosis, heart disease, or respiratory disease, or have dental needs.

Pregnancy and other gynecological care needs are a consideration for women who are incarcerated. Many female inmates are pregnant at some point during their imprisonment. Some women may require cesarean section or other gynecological procedures. Restraint systems become an issue, particularly when performing perineum checks or other postoperative checks. Hospital policy should be followed regarding the use of shackles with female patients. Patient privacy is another concern. Male corrections personnel may supervise female inmates. The nurse should inform corrections personnel that he or she will draw the curtain and perform the examination in private.

Concerns regarding pain management. Pain management is an issue for many patients--those with multiple trauma, those with advanced forms of cancer, and postoperative patients. Many people who are incarcerated have a history of illegal drug use; thus, pain management can become an issue, particularly if nurses or other health care providers perceive patients as drug-seeking. As with all patients, appropriate postoperative pain management is an important aspect of quality care. Withholding or refusing to medicate a patient who complains of pain or demonstrates physiological signs and symptoms of pain is a form of patient harm. A complete nursing assessment for pain management is warranted for all postoperative patients, including patients who are incarcerated. It may be necessary to educate other health care providers (eg, other nurses, physicians) about the necessity of self-reflexive assessment, especially for a provider who has difficulty providing adequate pain control for a patient who is incarcerated. A reflexive health care provider is able to recognize when his or her political or moral views interfere with quality and compassionate patient care, regardless of who the patient is thought to be. If a provider seems reticent to provide adequate pain management, a review of the signs of pain (eg, tachypnea, tachycardia, posturing) may help him or her see the need for prompt and complete pain control.

Communicating discharge or transfer information to other health care providers. Discharge is an important time in any patient's hospital stay. A frequently used axiom in nursing is that discharge planning begins at the time of admission. This is especially true for people who receive care while in custody. Nurses will need to determine who should receive discharge plans, who to contact to schedule follow-up appointments, and the patient's specific treatment needs after the procedure. The patient should receive discharge instructions, as he or she may be providing his or her own postoperative care.

Use clear and simple language when explaining postoperative care and treatment to a patient who is incarcerated. Knowing what complications may develop can help a patient more thoroughly explain the need for reexamination and treatment. It also is necessary to contact medical personnel at the corrections facility with discharge and treatment information. Ask this person what records need to accompany the patient to the corrections facility, and make sure that this packet is copied, marked confidential, and sent to the facility at the time of transfer.

Visiting. In corrections institutions, visiting hours are enforced strictly, and all visitors are subject to search upon entering the facility. Of great concern to corrections personnel is that a visitor will bring contraband materials (eg, weapons, illegal substances, escape plans) to a person in custody. While the inmate is hospitalized, visits by family members, friends, or others often is not allowed. It is imperative that nursing staff members honor the wishes of corrections personnel in this regard; doing so will decrease the level of tension that may exist surrounding care of a patient who is incarcerated. The lack of visitors and social support during hospitalization increases the need to provide a supportive care environment to expedite the patient's return to an improved level of health.

EDUCATIONAL AND POLICY IMPLICATIONS FOR PERIOPERATIVE NURSES

Caring for people in custody can be challenging, offering a change from daily nursing care routines and the chance to provide services to a population of individuals who will benefit from a high degree of quality care. They often are undereducated; are from families that are impoverished or otherwise devastated due to previous incarceration, drug use, or violence; and may have a difficult time fitting into society. They require the same, if not a greater, degree of caring when ill than other groups as a result of their difficulties in society.

People who are incarcerated may have received little education about the body's functions, illness and wellness, or other health-related issues because of their family history. Patient education becomes an important aspect of their care. Providing sufficient postoperative instructions and finding ways to allow them to easily comply with treatment may hasten their return to health. This is important because the correctional facility may not have the same supplies as the health care facility. Inmates may experience delays in reexamination, and this possibility must be taken into account when providing postoperative care instructions and supplies.

The development of policies for the safe and effective care of incarcerated populations must be undertaken by nursing units and facilities before admission of individuals in custody. Scrambling to develop makeshift policies after a patient has arrived will not meet the needs of the patient or health care providers. Information from the American Public

Health Association and the United Nations Standard Minimum Rules for the Treatment of Prisoners can direct the development of guidelines for the care of incarcerated populations. (38) Additional information on the historical treatment of incarcerated populations also can be obtained from two private agencies, Amnesty International and Human Rights Watch. (39) These organizations identify and report on the mistreatment of imprisoned populations, and their work may be useful in identifying areas of potential concern.

Care provision for people who are incarcerated can be a thought-provoking and, ultimately, rewarding experience. Being well prepared to meet the needs of this challenging population is a key factor in the successful provision of health care services to incarcerated populations.

The author wishes to thank Shana Cantoni, RN, BSN, staff nurse, Harborview Medical Center, Seattle, and Kathy Smith-DiJulio, RN, MA, lecturer, department of psychosocial and community health, University of Washington School of Nursing, Seattle, for their insight and assistance.

Editor's note: This article was funded by a National Research Service Award # 1F31 NR07529-02 from the National Institutes of Nursing Research, the National Institutes of Health, and the Warren G. Magnuson Scholarship for the Health Sciences.

NOTES

(1.) A J Beck, "Prison and jail inmates at midyear 1999," Bureau of Justice Statistics' Bulletin (April 2000) 1-12.

(2.) Ibid; M Mauer, Race to Incarcerate (New York: The New Press, 1999).

(3.) Beck, "Prison and jail inmates at midyear 1999," 1-12.

(4.) Ibid.

(5.) T R Clear, G F Cole, American Corrections, fourth ed, (Belmont, Calif: Wadsworth Publishing Co, 1997).

(6.) "Criminal offenders statistics," US Department of Justice, http:// www.ojp.usdoj.gov/bjs/crimoff.htm (accessed 16 Jan 2002).

(7.) E F Torrey, "Jails and prisons: America's new mental hospitals," American Journal of Public Health 85 (Dec 1995) 1611-1613.

(8.) "Criminal offenders statistics."

(9.) Amnesty International, "Pregnant and imprisoned in the United States," Birth 27 no 4 (2000) 266-271.

(10.) A F Gordon, "Globalism and the prison industrial complex: An interview with Angela Davis," Race and Class 40 no 2/3 (1999) 145-157.

(11.) Mauer, Race to Incarcerate.

(12.) C J Mumola, Substance Abuse and Treatment, State and Federal Prisoners, 1997 (Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, 1999).

(13.) P M Ditton, "Mental health and treatment of inmates and probationers," Bureau of Justice Statistics, Special Report (July 1999) 1-12.

(14.) A J Beck, J C Karberg, "Prison and jail inmates at midyear 2000," Bureau of Justice Statistics Bulletin (March 2001) 1-12.

(15.) M H Tonry, Malign Neglect--Race, Crime, and Punishment in America (New York: Oxford University Press, 1995).

(16.) Ibid; Mauer, Race to Incarcerate; J G Miller, Search and Destroy: African-American Males in the Criminal .Justice System (New York: Cambridge University Press, 1996).

(17.) Miller, Search and Destroy: African-American Males in the Criminal Justice System.

(18.) Tonry, Malign Neglect--Race, Crime, and Punishment in America.

(19.) "Criminal offenders statistics."

(20). Mauer, Race to Incarcerate.

(21.) E C Hostetter, D T Jinnah, "Research summary: Families of adult prisoners," Family and Correctional Network, http://www.fcnetwork.org/ reading/researc.html (accessed 14 Jan 2002).

(22.) D F Reed, E L Reed, "Children of incarcerated parents," Social Justice 24 no 3 (1997) 152-170.

(23.) Ibid, 155-156.

(24.) Cynthia Beatty, Parents in Prison: Children in Crisis. An Issue Brief(Washington, DC: CWLA Press, 1997).

(25.) E M Grieco, "The White population: Census 2000 brief," US Census Bureau, http://www.census.gov/ prod/2001 pubs/c2kbr01-4.pdf (accessed 25 Jan 2002); Beck, Karberg, "Prison and jail inmates at midyear 2000," 1-12.

(26.) Beck, Karberg, "Prison and jail inmates at midyear 2000," 1-12.

(27.) A Hall, Incarceration: Its Impact on African American Families and Communities (Knoxville, Tenn: Society for the Study of Social Problems, 1988).

(28.) Grieco, "The White population: Census 2000 brief"; J McKinnon, "The Black population: Census 2000 brief," US Census Bureau, http://www.census.gov/ prod/2001 pubs/c2kbr01-5.pdf (accessed 25 Jan 2002); Hall, Incarceration: Its Impact on African American Families and Communities.

(29.) A M Hornblum, Acres of Skin: Human Experiments at Holmesburg Prison: A Story of Abuse and Exploitation in the Name of Medical Science (New York: Routledge, 1998).

(30.) D S Young, "Women's perceptions of health care in prison," Health Care for Women International 21 (April/May 2000) 219-234.

(31.) Ibid.

(32.) A J Beck, Prisoners in 2000 (Washington, DC: US Department of Justice, Bureau of Justice Statistics, 2001).

(33.) Miller, Search and Destroy: African-American Males in the Criminal Justice System.

(34.) Ibid.

(35.) Ibid

(36.) Ibid.

(37.) "Criminal offenders statistics."

(38.) American Public Health Association, http://www.apha.org (accessed 14 Jan 2002); E H Ofori-Amankwah, United Nations Standard Minimum Rules for the Treatment of Prisoners (Lahore, Pakistan: Law Pub Co, 1979).

(39.) Amnesty International, http://www.amnesty.org (accessed 14 Jan 2002); Human Rights Watch, http://www.hrw.org (accessed 14 Jan 2002).

Cheryl L. Cooke, RN, MN, is a teaching assistant and doctoral candidate, University of Washington School of Nursing, Seattle.

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