Over the last decade the number of women being imprisoned in Scotland has increased dramatically where the average daily prison population of female offenders now exceeds 400 (The Scottish Government 2012). In numerical terms women offenders still constitute a very small proportion of the overall prison population, however the significant rise which has been evidenced over the last 10 years is disconcerting where a 69% increase in female imprisonment has been witnessed compared to just 25% within the male prison population (2001-2011) (REF). Evidence has indicated that one of the drivers for this observed increase is owed to women being convicted for longer periods of time for relatively minor offences (McIvor & Burman 2011).Women placed within the Criminal Justice System (CJS) have been found to be a particularly vulnerable population. Imprisonment presents profound effects on the already complex health care needs of these women but also carries with it a wider social and economic impact, in view of their role as mothers and carers (REF). The overall health of female offenders is poor with a large proportion of those incarcerated having more diverse and complex needs than those observed within the general female population. Many of these women will suffer significant physical and mental health issues which are often coupled with substance misuse addictions and backgrounds of violent or sexual abuse (REF). A large proportion have chaotic lifestyles which results in many female offenders accessing healthcare services for the first time upon imprisonment to treat on-going and undiagnosed conditions.
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The main purpose of this essay is to discuss the importance of understanding the health needs of female offenders in Scotland. The combination of the increase in the number of females being imprisoned along with evidence of complex health needs of this population present a major public health challenge which needs to be addressed. Not only is there a direct public health concern to the individual who is imprisoned but also a wider public health impact on the families and children of the aforementioned individuals.
This will be achieved by looking at the drivers for the increase in the number of women being imprisoned, and the need to understand their complex health needs in order to provide the correct implementation of services to accommodate these needs. The final part of this essay will put forward a public health approach which would allow the health needs of the female population to be explored.
The reasoning behind examining the health needs of the female offending population is on the premise of the author's current role as a Public Health Officer within the Forth Valley Public Health Department along with the author's particular interest in female offending and its wider public health impacts. The author's largest remit focuses upon the healthcare needs and provision of services for prisoners within Forth Valley's three distinct prison establishments (HMP Cornton Vale, HMP Polmont Young Offenders Institute and HMP Glenochil). Recent research carried out by the author into the need for the provision of Independent Advocacy services highlighted the large number of prisoners with mental health issues within Forth Valley prisons. During this research it was noted that there were significant gaps in knowledge with regards to evidencing the health needs of the female prison population within Scotland. Evidence is required to ensure that the correct provisions of services are available to meet the healthcare needs and often complex requirements of the female prison population. In turn this will help tailor services to the specific individuals needs providing a distinct person centred approach to healthcare for female offenders. The proposed study fits within the scope of public health research as NHS Boards now have the complete responsibility for prisoner healthcare which includes ensuring they have access to the correct provision of services which meet their needs.
Overview of female offending in Scotland
Trend in average daily population
Within Scotland the observed prison population on 30th June 2012 was 8,178 of which 94% were male (The Scottish Government 2012). For men, the rate of imprisonment for all ages in the general population is 237 per 100,000 and for women, 10 per 100,000, where men are 24 times as likely as women to be imprisoned (Prison Reform Trust 2012). Offending by women differs in a number of important ways from offending by men: it is less common, less frequent and less serious (McIvor 2007; Burman 2004). The significant rise in the number of women in custody can largely be explained by the increasing use of placing women on remand (REF). Over the ten year period of 2001-02 to 2010-11 there was a 46% increase in the number of women received into custody on remand in Scotland (REF). This increase equated to 1,893 women of whom only 30% went on to receive a custodial sentence. The overall average daily female prison population over the 10 year period (2001-02 to 2011-2012) has shown increasing trends every year, where the overall number has nearly doubled (Figure 1).
Always on Time
Marked to Standard
Trends in offences committed
Males and females vary in the crimes and offences that they commit although the patterns of crime are consistent year on year (REF). Women continue to commit relatively minor offences where the sentenced female population commit higher numbers of dishonesty and other crimes which consist mainly of drug related crimes. The sentenced male population commits higher numbers of non-sexual crimes of violence and crimes of indecency along with more miscellaneous offences (REF).
The increase in the young offender females who have been directly sentenced has been of concern within Scottish prisons with an increase of 13% against the 17% decrease observed in the young male offending population (REF). In 2009-10, twenty-one custodial sentences were imposed on children under the age of 16 which will evidentially increase the young offender population (REF). The average daily prison population by type of custody can be seen in Figure 2.
Trends in sentence length
The most common sentence length for the average daily female offender population is 6 months - less than 2 years followed by sentences of 2 years- less than 4 years (2002-02/2011-12). The average length of custodial sentences has increased from 228 days in 1999-2000 to 271 days in 2008-09 (REF). Sentence length is influenced by many factors, including a political approach with the Justice Secretary Kenny MacAskill noting that:
"Short sentences simply don't work. They are ineffective and of no practical benefit to communities."(Gardham 2009)
As of the 6th August 2010 a statutory presumption against short periods of imprisonment was decreed by the Scottish Parliament (REF). The Criminal Justice and Licensing (Scotland) Act states:
"A court must not pass a sentence of imprisonment for a term of three months or less on a person unless the court considers that no other method of dealing with the person is appropriate."
The Scottish Centre for Crime and Justice (SCCJR) produced a key document which considered the potential drivers for the increasing trend in female imprisonment observed in Scotland (REF). The report evidenced several factors including an increase in the number of women appearing before the court, being remanded in custody and being imprisoned for longer periods of time. There was also a substantial increase in the number of women committing drug offences which carry heavier custodial penalties; in 2010 24% of women were serving sentences for drug offences (REF). The report found no evidence that women were increasing their participation in crime, signifying that this disproportionate increase is more likely attributed to an increasing use of custodial sentences for women who have committed less serious crimes (REF).
Comparisons Nationally and Internationally
The observed increase in the number of females being imprisoned over the last decade is not a Scottish phenomenon. This increased trend has been observed throughout the UK and Internationally. The imprisonment rate per 100,000 of the population in Australia is 130 (Gelb 2003), which is just slightly lower than the UK at 149 and Scotland at 146 (Prison Reform Trust 2012). The United States the rate per 100,000 of the population is a staggering 716, where women offenders represented 17% of all offenders in 2003 (Bloom et al. 2004)
Female offending from a policy perspective
The Bangkok Rules (also known as the UN Rules for the Treatment of Women Prisoners and Non-Custodial Measures for Women) (REF) set out the minimum standards for the treatment of women offenders whether remanded or sentenced and were adopted by the UK Government in 2010 (REF). These rules were designed to fill the gap in International standards against the backdrop of increasing trends of female imprisonment. The International importance of these rules should not be underestimated; they are the first rules to address the surrounding issues of children of maternal imprisonment (Ministry of Justice 2012). Despite the adoption of the Bangkok Rules within the UK there is still a gap between putting policies into practice to fulfil their requirements. The incorporation of the rules into sentencing policies and legislation still remained problematic (Gullberg 2013).
The increase in the number of women being imprisoned has seen a rise in the publication of many influential reports. One of these was the Corston Review (2007) which was conducted in light of six deaths of female offenders in HMP Styal (REF). This review outlined the need for a holistic, integrated and women-centred approach in the CJS and produced forty-three recommendations. This review highlighted a wide range of issues in the prison estate including highlighting the high rates of mental health, substance misuse and prior physical and sexual abuse.
This Essay is
a Student's Work
In 2012 the Scottish Commission on Women Offenders (Angiolini 2012) produced a review of the CJS in Scotland, where the Commission put forward thirty-seven recommendations to improve the outcomes of female offenders. Thirty-three of the recommendations were subsequently accepted by the Scottish Government. Recommendations seven to ten explicitly note the mental health needs of female offending population putting forward a practical proposal to address these health needs (Table 1). An allocation for 2014-2015 of 20 million pounds has been given to the SPS to target the health needs of the female prison population (The Scottish Government 2013) In order accomplish true equality for female offenders it will be pivotal that the Government recognises that the health needs of female offenders is significantly different from their male counterparts and will therefore require specific health interventions which are gender specific (REF).
Mental health services and approaches should be developed in such a way that facilitates women with borderline personality disorder to access them
Mental health programmes and interventions for short-term prisoners are designed so that they can continue to be delivered in a seamless way in the community
The Scottish Government's mental health strategy must place a greater focus on women offenders, specifically the provision of services to address trauma, self-harm and borderline personality disorder
An urgent review of the provision and resourcing of services for women with borderline personality disorder and post-traumatic stress disorder (in relation to previous abuse and neglect) should be carried out
Social correlates of crime
The overall risk factors of becoming an offender begin early in life and increase throughout childhood. A significant proportion of imprisoned individuals come from families and communities who live in economic, social, material and emotional poverty (Graham 2007).
Studies comparing the lives of "delinquents" to "non- delinquents" have identified a number of risk factors for those who offend (Blackburn 1995). These include reduced family interactions; "parental deviation", family disruption and socioeconomic deprivation. There is also a disproportionately high prevalence of mental illness in both remand and sentenced prisoners (Department of Health 2001) which adds to the complexity of prisoner needs.
A report on Social Exclusion and Imprisonment in Scotland investigated the links between social deprivation and imprisonment rates (Houchin 2005). The results indicated that regardless of the age of the sample population the probability of imprisonment was highly correlated with levels of deprivation. It is important to note however that association is not causation (Bhopal 2008) as there is neither sufficient nor necessary cause that social deprivation is a precondition for imprisonment. This can be concluded by observing that there are many people who live in deprived communities who never enter prison and equally there are individuals in prison who do not come from deprived localities.
Social effects on the incarcerated female
Women have a different experience whilst being imprisoned compared to their fellow male offenders where the effects can be far more profound. The effects of maternal imprisonment on their families are generally more disruptive than the effects of paternal imprisonment (Davies 2011). Parental imprisonment has a dynamic impact upon children, who often become the forgotten victims of imprisonment (Loureiro 2009). Women are more likely than men to be the sole care giver for children with on average two- thirds of women in prison being parents of dependent children (Corston 2007). Around one-third of women who are imprisoned will lose their jobs, homes, possessions and children during their prison sentence (Niven and Stewart 2005). They may also find it difficult to maintain family ties due to the geographical location and distribution of women's prisons.
"Many women still define themselves and are defined by others by their role in the familyâ€¦â€¦To become a prisoner is almost by definition to become a bad mother"
(Baroness Hale, Corston Report 2007)
Each year in Scotland, more than 16,000 children are separated from a parent through imprisonment, with about 1,850 separated from an imprisoned mother (Scottish Government 2011). This number suggests that in Scotland more children experience a parent's imprisonment than a parent's divorce. The effect on the children of imprisoned parents can include a higher risk of future imprisonment themselves, higher risk of problems with physical and mental health and regressive behaviour (Loureiro 2009; Glover 2009).
Healthcare within the prison context
Healthcare delivery for prisoners has historically been the sole responsibility of the Scottish Prison Service (SPS) and not the National Health Service (NHS). Following the transfer of responsibility for healthcare from the SPS to the NHS in November 2011 (The Scottish Government, 2011) there is now a requirement for prisoners to have access to the same quality and appropriate range of healthcare services as those members of the public with similar needs. The emphasis is on achieving equity for healthcare and in doing so tackle inequalities in prisons (REF).
The Scottish Prison Services (SPS) guiding principles state that:
"Healthcare in prisons should be equivalent to that delivered in the community, that prison is part of public health and that the prison setting is potentially an opportunity for health promotion."
The transfer of responsibility for primary healthcare services to the NHS within Scotland was driven by tackling health inequalities, meeting accepted international standards, better continuity of care and sustainability (NHS Health Scotland 2011). The prison environment presents a challenging place to practice healthcare and be a patient due to loss of liberty, unequal power and restricted choice (Graham 2007) stripping the individual of their self- autonomy completely (Anaraki, Plugge & Hill 2003). Healthcare is available to prisoners from the moment of admission, where screening aims to identify and address prisoner healthcare needs. The increased numbers of women being imprisoned bring with it an increased demand and challenge for healthcare services within the prison setting (The Scottish Government 2008). Female offender needs include gender specific ones such as the need for gynaecological services, maternity care and the care of young babies within the prison setting (Edgar 2004). Imprisonment regardless of the individual's gender, age or length of imprisonment can include harmful psychological and emotional effects which can often exacerbate existing underlying unmet healthcare needs (REF).
Health needs of female offenders
There is considerable research to suggest that the prison population are at greater risk of developing mental health problems compared with people of a similar age and gender in the community (Liebling 1993). Mental health, substance misuse and self-harm needs are all prevalent within the female prison population although prevalence data into the full extent of mental health disorders within the prison is lacking (REF). Existing literature indicates that the majority of prisoners will have one or more mental health problems and may also have a dual diagnosis of substance misuse (REF). Not only does mental health directly impact an individual's quality of life but has also been linked to physical health, health related behaviours and mortality (REF).
The Office of National Statistics Survey (ONS)
The ONS survey (Singleton et al 1998) collected baseline data of the mental health of male and female, remand and sentenced prisoners across all prisons in England and Wales. The study described the extent and nature of mental health problems among prisoners. Sleep problems, general worry, fatigue and depression were prevalent among all prisoners especially those on remand with 90% of prisoners having one or more of the 5 psychiatric disorders studied (psychosis, neurosis, personality disorders, hazardous drinking and drug dependencies). Further findings can be seen in Table 2.---- explain the findings in the table
Mental health disorder
Prevalence within the prison population
55% of prisoners had some form of 'neurotic disorder'
Rates of neurotic disorders in remand and sentenced prisoners were much higher in women than in men
Neurotic disorders were found in 59% of men on remand and 40% of sentenced men compared with 76% of women on remand and 63% of sentenced women
10% of prisoners displayed symptoms of functional psychosis; the figure in the general population is 0.4%
Schizophrenia or delusional problems were the most prevalent
65% had some form of personality disorder; 78% of male remand and 64% of male sentenced and 50% of female prisoners on remand and sentenced
The most common was anti-social personality disorder
Scottish prevalence data
The findings of a study into the prevalence of psychiatric morbidity among remand prisoners in Scotland (Davidson et al 1995) reported the prevalence measures of the sample population (389 remand prisoners (18 women)) as;
2% major psychiatric disorder
14% severe depression
40% disturbed sleep
The prevalence of severe and enduring mental health problems in Scottish prisons was estimated to be 4.5% (The Scottish Government 2008) which is four times the level of the general population. Schizophrenia and bi-polar affective disorders being the most common problems identified within the study population. The prevalence on admission to Scottish prisons can be compared to the prevalence in the community (SPS 2007) (Table 3). The prevalence of personality disorders, schizophrenia and depression are considerably higher between the admitted populations compared to those in the community.
Table 3: Prevalence of health status of those on admission to prison and those in the community
Prevalence on admission to prison (females)
Prevalence in the community
The high prevalence of mental health needs evidence from Singleton, Davidson and SPS is substantiated
In HMP Cornton Vale the number of mental health referrals received was 837 in 2011 which is particularly high in comparison to the average daily population.
An average of 1 in 2 offenders in HMP Cornton Vale
In HMP Cornton Vale 16 prisoners were transferred to a psychiatric unit in 2011
Self- harm within the prison is higher for female offenders than males. Offenders identified as being at risk of self-harm and/or suicides are placed on the 'Act 2 Care' register. Over the period of May 2011 to April 2012, 221 women in Cornton Vale were placed on the register. Results from The ONS survey reported that suicidal thoughts were very high: 46% of female remand prisoners had thoughts of suicide over their lifetime, 35% in the last year and 12% in the week prior to interview.
Drug and alcohol dependency are common variables for offending (Liebling 2007)
Examples of drug and alcohol use before imprisonment, where alcohol dependency is particularly high.
Intoxicated at point of commission
Alcohol impinging upon ability to hold down a job
Concerned alcohol would be an issue upon release
Adverse effect on relationship with their families
Drug use an issue in the community
Under the influence of drugs at the time of the offence
Receiving treatment for drug addiction at time of offence
Committed offence to get money for drugs
Used drugs in 12 months prior to incarceration
Table 11- Social exclusion characteristics of the female and male Scottish offender population 2011
Source: Carnie J, Broderick R. Prisoner Survey 2011. Scottish Prison Survey 2011. Scottish Prison Service 13th Survey Bulletin, Strategy Unit
Prisoners are also more likely to be abusers of illegal drugs and alcohol than other sectors of the community.
In 2011, 42% of female offenders reported being intoxicated at time of committing their offense, compared to half (50%) of male offenders.
Fewer female prisoners (24%) in 2011 felt that drinking affected their ability to hold down a job compared to 29% in 2009. This brings the level to a comparable figure with male prisoners (25%).
A fifth of women prisoners (21%) were concerned that alcohol would be an issue upon their release, which is slightly lower than male prisoners (24%).
A third of women prisoners (34%) reported that drinking had affected their relationship with their family compared to 38% in male prisoners.
More female prisoners than male prisoners reported drug use to be a problem to them in the community (50% females; 40% males).
Higher numbers of female offenders stated that they were under the influence of drugs at the time of their offence (595 females; 44% males)
A third of women (35%) were receiving treatment for drug misuse before imprisonment compared to a fifth of male prisoners (20%).
34% of female prisoners had committed their offence to get money for drugs compared to 18% of male prisoners.
Seven in ten (71%) female prisoners reported that they had used drugs in the twelve months prior to coming into prison, compared to 61% of male prisoners
The prison environment itself can exacerbate the vulnerability of prisoners ( Liebling 2007), where many women experience psychological stress of loss of contact with children and substance misuse withdrawal.
Current service provision for female offenders
Independent Advocacy provision from July 2013
Mental health strategy
Public health approach - 700 (2hrs)
The research method of choice for exploring the health needs of the female prison population will be to carry out a health needs impact assessment.
The research question
What are the health needs of the Scottish female prison population?
Are current prison health care services tailored to the particular health care needs of the Scottish female prison population?
Strengths and weaknesses of using the proposed method
Better health, better care
Carry out the HNA in Cornton Vale, despite women now being held in X,Y,Z
Many studies have focused solely on mental health and substance misue within the prison population without exclusively evaluating the full health care needs of the female offending population.
Drivers for imprisonment
Poor health in comparison to the general population
The need for a person centred tailored approach to this vulnerable populations health care needs including ensuring that they have the provision of services tailored to these needs.
Holistic approach should be the norm