"Previous information on women who are incarcerated consistently revealed that women offenders experience very poor health services utilization in the community and while incarcerated, seek medical services to a greater extent than men."
A great amount of research over the last ten years has concentrated on assessing the treatment needs of women offenders who are drug-dependent compared with their male counterparts. One important finding of the research is that women who are incarcerated are more likely to report extensive histories of physical, emotional and sexual abuse; between 77-90%. The trauma resulting from these types of abuse is a key contributor to adolescent behavioral issues, substance abuse, delinquency, as well as criminal behavior among women.
In addition, surveys conducted among female offenders have consistently revealed a strong link between childhood abuse and adult mental health issues, especially depression, panic, PTSD, and eating disorders. The costs of failing to diagnose and appropriately treat psychiatric disorders among offenders are high and may include homelessness, unemployment, and loss of the custody of children. Research also revealed that women offenders who are drug-dependent are more likely than male offenders to experience chronic physical health issues. The health issues drug-dependent women offenders can experience include:
The health issues incarcerated women experience are compounded by the limited health care they receive prior to their incarceration. Previous information on women who are incarcerated consistently revealed that women offenders experience very poor health services utilization in the community and while incarcerated, seek medical services to a greater extent than men. Women offenders are usually impoverished, with resources and transportation that are inadequate, limiting their access to community-based health care systems. Access to health care that is adequate while they are incarcerated is often times limited due to the costs of providing the services, as well as the lack of visibility of the health care needs of women inmates.
The association of substance abuse, childhood abuse, crime and comorbidity among women offenders has led a number of researchers to propose comprehensive treatment interventions that address these issues. The cumulative toll on women's physical health; however, is many times excluded as a focal point of the interventions. Few efforts have provided explanatory models that outline factors which contribute to the disproportionate prevalence of physical and mental health issues among female offenders. Assessing potential predictors of the physical and mental health issues among women offenders who are drug-dependent can greatly inform criminal justice policy, particularly within a correctional system whose responsibility is to treat and house them.
The Adverse Childhood Experiences (ACE) Study
The, 'Adverse Childhood Experiences (ACE) Study,' demonstrated a link between childhood trauma and physical health issues. The ACE study found a strong relation between the cumulative number of events of childhood abuse and household dysfunction and multiple risk factors for the leading causes of death in adults - to include histories of depression, attempted suicide, and chronic drug dependency. ACE studies were conducted with people sampled from a large health maintenance organization (HMO) in a metropolitan area.
The sample was comprised of people who were more socially integrated than those in the criminal justice system. There is a strong likelihood that the link between childhood trauma and adult physical and mental health issues is greatly more pronounced among a female offender population due to:
On the basis of prior finding on women offenders and from the ACE studies, two hypotheses were presented. The first hypotheses suggests that increased exposure to childhood traumatic events among drug-dependent women offenders would be associated with greater histories of problem behaviors during adolescence and adulthood such as:
The second hypotheses suggests that greater exposure to childhood traumatic events, in combination with pre-existing substance abuse and criminal histories among the sample population, would increase the likelihood of adult physical and mental health issues.
Childhood Traumatic Events, Abuse, Neglect, and Household Dysfunction
Indicators of childhood traumatic events were based on self-reports of events before the age of 16 in response to items from the, 'Life Stressor Checklist (LSC-R). The LSC-R is designed to screen for the occurrence of 30 life events that meet the definition of, 'trauma,' according to the DSM-IV. It has demonstrated good criterion-related validity for PTSD in diverse populations of women and has been found to be an appropriate measure among people with co-occurring substance abuse and mental health disorders.
Emotional abuse or neglect was defined as being, 'emotionally abused or neglected through being embarrassed, frequently shamed, ignored, or repeatedly told that you were no good.' Physical neglect was defined as, 'being physically neglected by not being fed, appropriately clothed, or left to care for oneself while too young or ill.' Physical abuse was defined as being, 'abused or physically attacked by someone you knew, such as a parent, husband or boyfriend, who hit, choked, slapped, burned, or beat you up.' Sexual abuse encompassed being, 'touched or made to touch someone else in a sexual way because they forced you in some way, or threatened to harm you if you did not,' or, 'forced sex - whether oral, genital or anal, when you did not want to because someone forced you in some way, or threatened harm if you did not.'
Household dysfunction consisted of a number of possible components. Family violence was assessed by asking, 'Did you ever see violence between family members such as kicking, hitting, punching, or slapping' Parental separation/divorce was assessed by asking, 'Did your parents ever separate or divorce while you were living with them' An incarcerated family was defined as, 'a close family member being sent to jail or prison.' Out of home placement was defined as, 'being in foster care, or put up for adoption.'Women Offenders and Research Findings
There were significant increases in the proportions of women who had histories of homelessness, adolescent conduct disorder, as well as prior substance abuse treatment with greater exposure to childhood traumatic events. Between 62% and 76% of the women with 5 or more childhood traumatic events reported these histories, compared with 30% to 52% of those with no childhood traumatic events. Adolescent childbirth and loss of custody of children were not related to childhood traumatic events.
Following the analytic model of the ACE studies, researchers assessed the cumulative exposure to childhood traumatic events and health outcomes within a sample of drug-dependent women offenders. The sample had considerably greater overall exposure to childhood adverse events when compared with the HMO sample of women from the ACE studies. Women were substantially more likely to have reported each childhood traumatic event happening at least once before they reached the age of 16, compared with the HMO sample of women reporting the same or similar events happening before they reached the age of 18 years of age.
Researchers hypothesized and confirmed that increased exposure to childhood adverse events was associated with behavioral issues during adolescence and adulthood. There was a strong relation between the onset of criminal events and exposure to childhood traumatic events, with younger age of onset associated with greater exposure. The findings mirror national studies documenting the characteristics of girls in juvenile correctional facilities and substantiate the role that physical and sexual abuse played in their delinquency.
The researchers also found a strong and graded relation between the amount of exposure to childhood abuse and household dysfunction and adult physical and mental health issues. Childhood traumatic events were significantly and positively related to 12 of the 18 variables researchers examined. Effect sizes ranged from a 15% increase in odds of gynecological issues or poor health to a 40% increase in odds of mental health treatment, relative to an increase of 1 childhood traumatic event.
The biggest effect of exposure to childhood trauma was for the 5 mental health outcomes assessed by researchers. The resulting magnitude of the additive effects of exposure to multiple childhood traumatic events was shocking - a 980% increase in the odds of mental health treatment relative to exposure to 7 childhood traumatic events, particularly in light of the fact that researchers measured only the impact of whether the childhood traumatic event happened once before the age of 16 and not the actual frequency of the events during that period of time. The finding is key in regards to the general lack of appropriate mental health treatment available to women in correctional programs, as well as to the risk of recidivism associated with co-occurring mental health and substance abuse disorders.
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