Correctional Health Care since the Passage of PREA

Article excerpt

In 2003, Congress and President Bush issued a clarion call for change in American corrections to remedy the "dreadful degradation" of inmate sexual violence first described in 1826 by the Rev. Louis Dwight, president of the Boston Discipline Society. (1) Grounded in its commitment to the U.S. Constitution, the Prison Rape Elimination Act of 2003 (PREA) charted a course to identify, prevent, prosecute and respond to prison sexual violence in all correctional custodial institutions (adult and juvenile, public and private) and provide services to those victimized. In the four years since its passage, PREA has facilitated many positive, substantive changes in U.S. corrections, enhancing safety and security in institutions and the community. Many of these innovations have involved correctional health care and the delivery of much needed services to the victims.



Who Are the Victims?

Although it is recognized that anyone can be the victim of inmate sexual violence, research has demonstrated that certain inmates are at increased vulnerability (e.g., the young; those new to incarceration; those with mental, physical and developmental disabilities; gay, lesbian, bisexual and transgendered inmates; and those previously sexually victimized while incarcerated). Because of the staggering number of inmates with mental illness in adult (2) and juvenile (3) correctional facilities, this potential for victimization represents an enormous challenge for corrections. Additionally, reports indicate that among the incarcerated an overwhelming number of women (4) and a substantial number of men have been victims of physical and sexual abuse as children and adolescents. (5)


Correctional agencies are tasked with responding to a wide range of health care needs for victims of inmate sexual violence. In addition to injuries and trauma that may accompany sexual assault (often to get the victim to comply), a victim may be exposed to HIV/AIDS, other sexually transmitted diseases, and communicable diseases such as tuberculosis and hepatitis B and C, which are rampant in U.S. correctional institutions. (6) In addition to the provision of appropriate health care, forensic medical evidence must be properly and legally collected from the victim in a timely fashion if a criminal investigation or prosecution is to take place.

Emotionally, victims of inmate sexual violence may experience a variety of resultant problems, including suicidal ideation, post-traumatic stress disorder/rape trauma syndrome, anxiety, depression and a worsening of pre-existing mental health conditions. When victims face repeated victimization, they may view suicide as the only viable option. In the community, rape victims are four times more likely than noncrime victims to have contemplated suicide, and 13 times more likely to have made a suicide attempt. (7) However, the number of inmates who have attempted or completed suicide as a result of sexual violence is unknown. The effects of inmate sexual violence are also impacted by age and gender.

Impact on women. Incarcerated women have a much higher rate of physical and sexual victimization during childhood, adolescence and prior to their incarceration. (8) For women previously victimized, the impact of sexual violence during incarceration can be much harsher, interfering with their coping and recovery. Even worse, the ultimate betrayal of sexual abuse by correctional staff erodes their self-esteem and trust in the correctional system to protect them. (9) Women may also become pregnant as a result of their victimization.

Impact on men. Sexual assault devalues two primary aspects of male identity: sexuality and aggression. Most male victims experience concern about their masculinity, competence and security, which increases their humiliation and shame. (10) Men often manifest a more "controlled" response, which may lead authorities to conclude the event did not occur or to minimize its impact. …