Social injustice in a penal harm approach to healthcare: Women prisoners' accounts of provider-patient relationships

Background: Providing healthcare in jails and prisons presents well documented challenges. Discussions of these focus on the necessity of healthcare providers to manage the tension between the goals and values of healthcare and those of custody. An alternative perspective, penal harm, proposes that healthcare in US jails and prisons has abandoned care and compassion common in community practice and has adopted the principles of custody-containment and punishment. Findings from this study of healthcare access among formerly incarcerated women make visible the penal harm philosophy, its contribution to distrust of providers, and its stigmatizing effect on a marginalized and economically disadvantaged population. Method: This community-based participatory research project included 31 formerly incarcerated women. Focus group data were transcribed verbatim and analyzed using grounded theory. Participants' mean age was 38 years. Fourteen were White, 8 Hispanic, 6 African American, and 3 other. Their mean level of education was 12 years. They reported an average of 6 incarcerations in jail and 1 in prison. Results: Findings reveal four distortions in provider-patient relationships. These experiences contributed to prisoners' distrust and avoidance of providers inside jails and prisons and at re-entry to the community. Such avoidance reinforced well established health disparities and increased human suffering among incarcerated and formerly incarcerated women and the communities to which they return after release. Conclusions: Provider-patient relationships like those described have become instruments of punishment, degradation, and humiliation. These findings have implications for public health practices and raise questions of health justice for professionals working with this population.