About a decade into her life sentence, Alice Marie Johnson felt pain around a couple of her bottom teeth. A car accident 20 years earlier had led to an expensive restoration with dental implants, and special cleanings now would be needed to maintain them.
But when she went to the prison dentist, he gave her only one option: her teeth would have to come out.
Despite being a designated federal medical center, the dental office at the Bureau of Prisons facility in Carswell, Tx., where she was expected to spend the rest of her life, didn’t have the instruments to maintain her implants. In pain, and without opportunity to get a second opinion, Johnson agreed to what she called his “barbaric solution.”
“When the anesthesia wore completely off, I got a mirror out and opened my mouth,” Johnson wrote in her recently published After Life: My Journey from Incarceration to Freedom.
“My teeth were gone, and I stifled a sob. I slowly realized they’d yanked out something that I loved about myself.”
Released in 2018 at age 63 and now better known as the inmate who received clemency after reality star Kim Kardashian West brought her story to the White House, Johnson’s story offers a glimpse of how policy and practice at correctional institutions haven’t met the needs of female prisoners when they require specialized treatment, preventative care and emotional support as they age behind bars.
“There’s really lack of awareness that the prison population is aging and that we might need to do something about this,” Lisa C. Barry, an assistant professor at the University of Connecticut Center on Aging, said in an interview with The Crime Report.
In a recently published pilot study conducted at a women’s prison in Connecticut, Barry concluded that in order to provide optimal healthcare, correctional health care teams need greater understanding of female inmates they get older.
“Women who are incarcerated have unique experiences, both outside and inside of prison, that may impact their health and health management during incarceration,” she said. “Improved understanding of their unique health care needs is needed.”
Women Aging Behind Bars
About 219,000 women are now serving time in U.S. prisons and jails, according to a Prison Policy Initiative 2018 report. Minimum sentencing laws along with a greater likelihood of receiving a conviction for drug and property crimes, have led to a more than 700 percent increase in the number of female inmates, particularly in state correctional facilities, over the past four decades.
A quarter of women serving time in prisons and jails are awaiting trial.
Currently, almost 7,000 women are serving a life sentence at prisons in states including California, Alaska, Louisiana, Massachusetts, Maryland and Utah, according to the Sentencing Project.
Okahoma, Kentucky, South Dakota, Idaho, and Missouri are also states incarcerating women at the heaviest levels. About two-thirds of these women will have the prospect of parole after serving two or more decades.
Data show women receive life sentences at double the rate of males and are receiving convictions later in life. Combined with the general aging of the U.S. population these trends suggest that as the years of their sentences go by, the number of incarcerated women over age 50 will increase.
“It is a relatively small population that we’re talking about—still important, but just difficult when it gets to a public health standpoint,” says Barry, one of a handful of U.S.-based gerontologists who study the mental health and physical function of older female prisoners.
Limited Research on Female Inmates
Inmate surveys conducted periodically by the Bureau of Justice Statistics have indicated prevalence of more chronic illnesses and mental health disorders among prisoners. But the difficulty researchers face in getting inside prisons means that these self-reported surveys don’t have much comparable independent data.
Out of 12,486 scientific articles published in the past decade, a 2018 review found only 21 studies that include original data about the health care of prisoners over age 50 in U.S. state or federal prisons.
While the majority focused on men, a 2014 study of 327 women, average age 56, incarcerated at prisons in five states in the South found female inmates averaged four chronic medical conditions and received five daily medications, had frequently histories of victimization, high rates of mental health issues and challenges with negotiating health care.
This gap in research data appears to be reflected in the recommendations corrections health experts thus far have offered on healthcare programming and practice for older female inmates.
In a position paper, adopted in 1994 and reaffirmed in 2014, the National Commission on Correctional Health Care advises correctional health staff to make sure women over 50 receive diets with reduced sodium, recommended amounts of B-12 and calcium, as well as treatment for menopausal hot flashes.
The 1976 Supreme Court decision on Estelle v Gamble gave inmates a constitutional right to health care. Federal facilities guarantee female inmates treatment for childbirth related care as well as for physical, mental, and substance-related illness. Most states have policies regarding reproductive health care for incarcerated women.
Nonetheless, “there is no comprehensive review of how these policies are implemented across the states and whether the care and services provided meet [national standards],” The Center for Prisoner Health and Human Rights has observed.
Presidential Campaigns Take Notice
Calls to address women’s needs have gained some traction over the past year. U.S. Sen. Elizabeth Warren (D-Mass) along with U.S. Sen. Cory Booker (D-NJ) this spring, reintroduced the Dignity for Incarcerated Women Act, legislation that would improve programming and visitation policies for inmates who also are parents with provisions aimed at helping women better prepare for returning home.
Improving conditions for female inmates also has been trending since the passage of the First Step Act. The Department of Justice in July announced that it would use part of the $75 million Congress allocated to the agency to implement the December 2018 law to expand programs to meet the needs of female inmates.
But thus far, none of these proposals reflect insights into the health care needs of older female inmates found in past research or revealed in Barry’s pilot study.
The data indicate that women aging in prison, like their male counterparts, are sicker than non-incarcerated women. Because of this, the National Institute on Corrections and some state prisons systems classify inmates at “elderly” when they turn age 50. Incarcerated females have higher rates of chronic medical disorders, psychiatric disorders and drug dependence before receiving a prison sentence than men. Once inside, they seek medical care two and a half times as often of male prisoners.
Many justice-involved women have had traumatic life experiences and present with trauma-related conditions that may obscure recognition and treatment for other chronic medical illnesses, according to some studies.
But not much is known about their health care needs as they get older on the inside.
To move this research forward, Barry led two focus groups with female corrections health care providers at York Correctional Institution, the only women’s prison within the Connecticut State Department of Correction. In 2008, York was named facility of the year by the NCCHC for its excellence in health service delivery. During the period of the study, UConn Health managed care at Connecticut prisons.
“In order to frame what some of these individuals are going through, I thought that it might be helpful also to get the perspective of the health care workers who are actually dealing with them on a day-to-day basis.” Barry said.
During conversations with prison nurses, social workers and other health care staff, Barry learned that perceptions of aging among their patients have more to do with the incarcerated woman’s health than her chronological age.
“I have a lot of patients in their 40s who are at higher risk or have more illnesses than a lot of older people do probably out in the community,” one focus group participant said. “We have some 40-year-olds here that can easily pass for 60 or better.”
The participant added: “When I think of old inmates, for me that’s not necessarily a number as much as it is a complete mental and physical condition. When you look at them physically, I am often shocked when I finally realize what an inmate’s age is.”
Among the patients they considered “older,” the correctional health care providers in the focus group described lower cognitive functioning, which they attributed to years of abuse and trauma.
“With the elderly inmates, they seem to have cognitive deterioration a lot faster than the general public because of all the substance abuse, head injuries with domestic violence, crime on the streets, all of that,” said a focus group member.
“[Female inmates who] are 50 and above have such a higher rate of cognitive deterioration and all the other symptoms that go with that and it gets hard sometimes to actually diagnose,” another commented.
Focus group members also told Barry that they need to spend more time with their older female prisoners, which they said, is difficult in the prison setting.
“I take time to explain it to them, I repeat it, I speak louder. I feel like I drop things to make sure I spend time with them, which ends up being probably longer than I would have normally spent,” one said.
“The older they are, I think the more their needs are. It’s not, ‘Okay take your pill and be quiet.’ You really need to listen to that person, you need to give a little bit more of attention.”
Existing Policies Don’t Reflect Patient Challenges
Even as the Bureau of Prisons (BOP) acknowledges findings that the majority of justice-involved women have experienced trauma, practice and policy even at federal correctional institutions hasn’t reflected these insights.
“We found that BOP may not be able to provide its trauma treatment program to all eligible female inmates until late in their incarceration, if at all, because BOP has assigned only one staff member at each institution to offer this program,” according to a September 2018 report by the Office of the Inspector General (OIG).
And although BOP requires its staff to undergo trauma-informed correctional care, “BOP does not require the same training for its executive staff. As a result, officials may develop policy and make decisions that affect female inmates without awareness of their needs,” the OIG found.
Negative perceptions of therapy among inmates also may delay facilities from offering and women from accepting mental health services and for some inmates result in a lifetime of cycling in and out of prison.
“Therapy is taboo…If you’re incarcerated, it’s taboo,” said Natalie Venegas, a mental health case manager for Los Angeles-based reentry program HomeBoy Industries. Venegas served four convictions during her twenties completing her last prison sentence in 2008.
“I didn’t know I had trauma,” Venegas said.
As justice-involved women get older, unresolved issues related to trust, grief, loss and never seeing themselves anywhere but inside a prison cell continue, Venegas said.
These unresolved external issues combined with prison policies that aren’t informed by research may hinder optimal care. In her study, Barry found that protocol at York Correctional Institution didn’t appear to acknowledge the cognitive declines and traumatic experiences incarcerated women have experienced. Some of the logistics at the prison made it difficult for health care staff to administer preventative care.
For example, focus group members in 2015 reported that the prison used the same “court run” bus that it dispatched to pick up new inmates from the state’s courthouses to transport its current inmates to outside facilities to receive tests such as mammograms. They observed that for some older inmates, the trips could be physically and emotionally challenging as well as provoke anxiety resulting in them refusing to get on the bus.
“Even though they know they should get a mammogram and they know it’s important, sometimes you have to do a lot of convincing and a sales pitch because they say, “ ‘Oh I’m not getting up at 4:30 to be handcuffed and all this to go to another facility,’” one caregiver said.
“I had to explain to her that she was going to be going [for an echocardiogram]. She said, ‘The court run! The court run!’ and she just started crying and saying ‘I’m not going to go! I’m just going to sign no for everything, I don’t care.’
“She was very, very upset that she would have to go on this court run. She said, ‘You know, you don’t know how it makes me feel. I have this trauma, it just scares me so much, and I know I’m not there to go to court, but I’m scared,’”
Prior research hasn’t indicated how these logistics could be a barrier to optimal care, Barry said.
“Having to get up at the crack of dawn and get on the court run bus with potentially some really noisy, young women that could be really intimidating and they would rather forgo medical treatment than go through that whole procedure just to get a certain treatment—that was really eye opening,” she said.
Sections of the First Step Act and similar legislation passed in several states in recent months are designed to remedy the health risks associated with confining pregnant women and put an end to the excessive charges for basic hygiene products.
However, as women age behind bars, their hygiene and health-care related needs may go beyond receiving an adequate supply of toothpaste, toilet paper and tampons.
“Mattresses … biggest complaint,” said one prison caregiver. “They’re this thin [holds fingers apart two to three inches] and the frame is metal. It goes right to their head. They’re in more pain. They’re not sleeping.”
For women who can’t afford to purchase additional blankets, this inadequate bedding could have a negative impact on sleep hygiene, the provider noted.
And then there are challenges for women getting around a prison structure that wasn’t designed for serving as a long-term home for people developing mobility related health conditions.
“There’s people who have walkers and they live up on a tier. They have to go up the stairs. There was one woman would throw her walker up and then go up the stairs,” recalled one prison caregiver.
In addition to meeting their patient’s physical and mental health care needs, prison policies made it a challenge for providers to gain approval for things like getting a patient a cane, a walker or a pair of hospital socks with treads.
In addition to the stress mothers serving time may feel when their prison term prevents them from filling a caregiver role for their young children, older female inmates also feel emotional stress because they aren’t able to take care of their own parents.
“I just met someone today actually who is here for DUI [driving under the influence], and she was all upset, particularly about herself,” one focus group member said.
“But she just found out that her 83-year-old mother was diagnosed with colon cancer and so now she’ s just so guilty for being here and worrying about her mother, she just broke down in tears. I just felt terrible.
“So it’ s not only their individual problems being an inmate but they usually have older parents or relatives that they’ re concerned about. They’re so afraid they aren’t going to get out before their parents die.”
With fewer female prisons, women often are incarcerated further from home, which makes visits with family more difficult and expensive.
Alice Johnson’s Struggle
Johnson began serving her life sentence for drug conspiracy charges at a facility in California several states away of her family in Memphis, Tennessee. Her youngest child was still in high school.
She wasn’t able to experience more frequent visits with her four children until 16 years into her prison sentence after a transfer to a facility in Alabama, still a three-hour drive away. During her time behind bars, Johnson’s mother was diagnosed with Alzheimer’s disease. She lost both of her parents during the 21 years she was incarcerated.
While men experience similar concerns about not being around to care for their parents and children, “this stressor is likely to be particularly salient for older female prisoners,” Barry says.
“As the number of older incarcerated women continues to grow, studies will be needed to evaluate the phenomenon of caregiving for older parents from behind bars. The correctional system may need to consider special programming to support women who, if not for being incarcerated, would be caring for elderly relatives,” Barry said.
The inability to operate within the full spectrum of caregiving also may have an impact on delivery of care as well as on prison healthcare workers themselves. Study participants said they found rules barring empathy in the form of a pat on the back or a verbal word of encouragement a challenge to their mission as caregivers.
“When I worked on the outside you could have somebody like that and it’s okay to give them comfort and it’s okay to hold their hand and say, you know, “I know you’re scared, you’re going to be fine,” and that is sometimes helpful. But here, you can’t do that,” one focus group participant said.
“That’s the hardest part of working here. You want to give it [compassion] to them, but you can’t. You’ll get ‘undue familiarity.’ You’re doing more for one than you would do for anyone else.”
At York, inmate prison numbers remain with prisoners for life and this also could hinder health-related outcomes for women.
“Their inmate numbers show how long ago they first came here so having a low inmate number and coming back in is considered, like embarrassing,” one prison health care worker observed. “[There’s] a little bit of shame, like wow, and even the officers will sometimes say to them, “You’re too old for this!”
If the goal of prisons is to rehabilitate, this may not be the optimal approach, Venegas, the Los Angeles-based case manager, says. “Everybody comes from a place where you don’t trust anyone. You have to receive them with open arms and not shame them. It’s all about empowering them.”
Even as this study recorded the insights from correctional health care workers at one state prison, Barry said that the project takes research a step forward in understanding how policy makers might respond to healthcare needs of women in prison as they age behind bars.
“These pilot study findings highlight opportunities for research and encourage further examination of the unique experiences of these women,” Barry told The Crime Report.
“As the body of work regarding the health of older female prisoners grows, the findings can be used to inform and shape policies to optimize the health and health care for this highly vulnerable population.”
Cassie M. Chew is a 2019 Journalists in Aging fellow based in Washington, D.C. and a 2019 John Jay/Arnold Justice Reporting Fellow. This article was written with the support of the Gerontological Society of America, Journalists Network on Generations, the Retirement Research Foundation and the Center for Health Journalism.