* In 1997, the US Department of Justice investigation into Los Angeles' jails reported a serious lack of mental health staffing. The Department's expert consultants believed that the maximum caseload for a "typical" jail psychiatrist should be approximately 75-100 inmates. At the women's jail (Sybil Brand Institute) there was "at most", one psychiatrist available, with an average caseload of 415 women, including more than 300 inmates on psychotropic medications. There were many more who the consultants considered "desperately need to be seen and likely medicated." [ US Department of Justice investigation of Los Angeles County Jail, 1997." Before the report of the investigation was completed the facility was closed and women were moved to another facility, and new staff were hired. The Justice Department stated that it had not assessed the new facility but said "it appears that mental health staffing continues to be inadequate": page 9, footnote 4.].
* In Florida in 1998, the Correctional Medical Authority (a state body that monitors health care in prisons) reviewed services at the Jefferson Correctional Institution -a prison for women - and found that there were problems caused by the failure to fill vacant positions in both physical and mental health services. The Authority reported that "psychiatric care, particularly medication management and continuity of care, was significantly compromised by the persistent staffing deficiencies." The prison had two psychiatrist positions which were both vacant at the time of the review; one had been vacant for more than a year. There was one psychiatrist on staff who had been appointed on a temporary basis [ State of Florida, Correctional Medical Authority, Physical and Mental Health Survey Report of Jefferson Correctional Institution Conducted September 1-3, 1998.]. The review expressed particular concerns about the use of psychotropic medication and cited the following instances:
* five inmates' records "lacked documentation of clinical rationale for various medication choices and dosages";
* in one case psychotropic medication was prescribed where it was "not the drug of first choice" for the disorder that had been diagnosed and in another case it was prescribed for diagnosed conditions which "are generally not amenable to treatment with medication";
* in three cases necessary laboratory testing for patients on psychotropic medication was either omitted (in one case despite being requested three times) or delayed (in one case for seven months after medication was prescribed).Lack of treatment for substance abuse
"The failure to rehabilitate substance-abusing inmates may be the greatest missed opportunity in the war on crime."
National study of drug abuse and treatment, which reported that treatment programs can reduce recidivism and relapse to drugs[ The National Center on Addiction and Substance Abuse at Columbia University, Behind Bars: Substance Abuse and America's Prison Population, The National Center on Addiction and Substance Abuse at Columbia University, 153. A recently reported study of substance abuse treatment also found that treatment reduced substance abuse and criminality for at least 5 years. The study was conducted by USA government agency Office of Applied Studies of the Substance Abuse and Mental Health Services Administration and is cited in Corrections Compendium, Volume 23, Number 11, November 1998, 27.].As described earlier, the war on drugs has resulted in a massive increase in the incarceration of women and men for violating drug laws. Among this group, and among many other offenders, are large numbers of people who have used and abused legal and illegal drugs. Surveys consistently show a large gap between available substance abuse and treatment -and inmate participation - and the need for such treatment and participation [The National Center on Addiction and Substance Abuse at Columbia University, Behind Bars: Substance Abuse and America's Prison Population, The National Center on Addiction and Substance Abuse at Columbia University, New York, 1998, 10.].
The most recent survey of prisoners [ C Mumola, Substance Abuse and Treatment, State and Federal Prisoners, 1997, Bureau of Justice Statistics, Washington DC, 1999.] was conducted in 1997 and found the following:
Substance Abuse and Treatment, Prisoners 1997.
State Federal Female Male Female Male Had used drugs regularly* (%) * once a week for more than at least a month 40 69 47 58 Used drugs at time of offence (%) 40 32 19 23 Alcohol or drug-involved prisoners treated for substance abuse since admission to prison (%) 20 14 13 12
According to the survey, the number of prisoners with a history of drug abuse has been growing but the proportion of prisoners receiving substance abuse treatment has declined. In 1991, about 40 percent of prisoners who used drugs at the time of their offence participated in drug treatment programs in prison; in 1997, the proportion fell to 18 percent [While the proportion of those receiving "treatment" fell, enrolment in other drug abuse programs, as "self-help" and "peer groups", increased during the period.].The US Congress has authorised the provision of funds to assist state and local correctional facilities to develop substance abuse programs and the US Department of Justice has indicated that it considers the development of prison-based women's treatment programs "a priority." [ Undated statement released by Corrections Program office, Office of Justice Programs, US Department of Justice.]. It is too early to assess the impact of the federal funding on the gap between services and treatment needs, particularly as the number of incarcerated women continues to grow.
Lack of counselling services
"The high rates of exposure to psychological trauma experienced by women in (prison), coupled with the association...between such trauma and the psychiatric disorders that were elevated among the women inmates, suggest that programs may be needed in women's prisons to address exposure to trauma and its sequelae. Many of the behaviours that appear to be related to being arrested and sent to prison eg impulsivity and use of illicit substances, are symptoms that are often associated with exposure to trauma and trauma-related disorders..."
Study of psychiatric disorders among women in prison in North Carolina [ K Jordan et al, "Prevalence of Psychiatric Disorders Among Incarcerated Women - II - Convicted Felons Entering Prison," Archives of General Psychiatry, Volume 53, June 1996, 513-519, 518.]."...the bulk of the interventions needed to help women improve their mental health is not about pills and not limited to the relatively small number of cases where a serious mental illness requires acute hospitalization and care...The fact is we have a lot of experience helping women in the community - in drug counselling programs, rape counselling centers, battered women's shelters and battered women's support groups, mothering groups and public health education - and very little if any of that expertise is reaching women in prison, who are actually the group most in need of such services."
Dr T A Kupers, psychiatrist, California, January 1999 [Communication to Amnesty International. Dr Kupers is Co-Chair, American Association of Community Psychiatrists Committee on Mentally Ill Behind Bars.].According to reports received by Amnesty International, jails and prisons generally provide services only for what are considered to be the most acute mental health disorders and commonly are unable to provide treatment other than medication. For example, at Valley State Prison for Women in California, Dr Kunkel, the chief prison psychiatrist, told Amnesty International delegates in November 1998 that the prison had too few health care staff to provide a significant amount of counselling and so did not, as a matter of course, provide services to women assessed as having post-traumatic stress disorder. As reported in chapter IV, only nine of 52 corrections departments reported in 1997 that they offered programs for victims of sexual assault.
Women currently or recently imprisoned in Illinois, Michigan and California told Amnesty International that psychotropic medication is often prescribed because other forms of treatment such as psychotherapy are not available. The US Justice Department investigation of jails in Los Angeles, cited earlier in this chapter, reported that although mental health staff were strongly committed to providing mental health care other than psychotropic medication, "their attempts at programming and therapy were overwhelmed by a lack of office and treatment space and inadequate staffing ["The lack of counselling and apparently associated reliance on medication is common to incarcerated men and women e.g. see evaluation of North Carolina Central Prison and McCain Correctional Hospital health care services, which found that "there is a lack of treatment other than medication" (page 4) and "Little individual counselling or group therapy is taking place." (Page 5): National Institute of Corrections Technical Assistance Report for the North Carolina Department of Correction, Division of Prisons (NIC Technical Assistance No. 98P1025)].
California psychiatrist Dr Terry A Kupers has noted:
"Many prison mental health services are limited to a psychiatrist who visits periodically to prescribe strong anti-psychotic medications. There may also be a few psychologists who spend most of their time administering psychological tests for courts and the parole board, and nurses who barely have time to evaluate emergency cases and pass out pills. But there is no place for a woman who has been massively traumatized and feels depressed or angry to talk through her traumatic memories in a therapeutic setting." [ T Kupers, Prison Madness - The Mental Health Crisis Behind Bars and What We Must Do About It, Josey Bass, California, 1999 (forthcoming), 132.].
Dr Kupers warns that unless facilities are able actively to identify women who have been abused and to provide services to assist them, these women are more likely to leave jails and prisons and "return to the kinds of abusive relationships that led to their law-breaking and imprisonment." [ Ibid., 132.]. Similarly, a study of psychiatric disorders among women in jail describes the predominance of post-traumatic stress disorder as "a relatively unexplored, but important, aspect" of women's mental health needs because of the severe psychological and behavioural repercussions of untreated trauma [ L Teplin et al, "Prevalence of Psychiatric Disorders Among Incarcerated Women - I. Pretrial Jail Detainees," Archives of General Psychiatry, Volume 53, June 1996, 511.].Concerns about the use of psychotropic medication
"Medication shall meet the best health needs of the patient, shall be given to a patient only for therapeutic or diagnostic purposes and shall never be administered as a punishment, or for the convenience of others."
Principle 10, UN Principles for the protection of persons with mental illness and the improvement of mental health careIn 1990, Arizona prisoner Dannie Martin wrote "it is ironic that men who are spending decades incarcerated for illegal drug activities are now doped up by government doctors to help them bear the agony of their sentences." In 1998, Amnesty International heard similar comments from former inmates, lawyers and others about the provision of psychotropic medication, which is used for psychiatric disorders, to women held in prisons and jails in the US. As the preceding section indicates, a number of studies and observers have expressed concern that psychotropic medication is being used because other therapies are not available. Further, concerns have been expressed that some of the circumstances of the use of psychotropic medication are inappropriate because it has been used for purposes other than the treatment of psychiatric disorders, for example, to help inmates to cope with the stress of incarceration.
In a recent study of women in a California prison who had participated in or caused the death of a battering male partner, many women reported that they were pressured into taking psychotropic medication while detained in jail before being tried [ K Auerhahn and E Leonard, "Docile Bodies? Chemical Restraints and the Female Inmate," Paper presented at the American Society of Criminology, Washington, DC, November 1998. These researchers hypothesise that the real purpose of the use of psychotropic medication in the circumstances they studied was to change the behaviour of women regarded as deviant, rather than to treat psychiatric illness.]. A number of the women reported that drugs were often ordered by psychologists and even correctional officers, people who are not qualified to diagnose the psychiatric conditions for which the medications are appropriate treatment and who are not legally permitted to prescribe medications. Some of the women in the study reported that the amount and mixture of drugs made it difficult for them to comprehend what was happening and adversely affected their ability to function during their trial. Lawyers in California, Illinois and Pennsylvania have also told Amnesty International that they have had clients who were so heavily drugged they had considerable difficulty communicating with them. A lawyer representing inmates at Valley State Prison for Women has drawn the issue to the attention of the United Nations Special Rapporteur on Violence Against Women:
"Rather than consistent treatment, women are prescribed heavy doses of psychotropic medications...I interviewed one mentally disabled woman who was so heavily drugged that she shook almost uncontrollably and could hardly speak throughout the interview. The relative incapacitation that accompanies such high doses of psychotropic medication renders women extremely vulnerable to sexual abuse and harassment." [ Cassandra Shaylor, Memo to Radhika Coomaraswamy, UN Special Rapporteur on Violence Against Women, May 18, 1998.].
The use of non-medical staff
In a number of correctional systems inmates must obtain the permission of non-medical staff in order to be attended by a doctor. In 1995, the US Department of Justice investigation into Julia Tutwiler Prison for Women in Alabama was highly critical of the obstacle to medical access created by the use of non-medical staff:
To get an appointment with the doctor, inmates must first sign up for sick call during mealtime. Sick call takes place in the middle of the night, and is primarily a screening process conducted by unsupervised and unqualified (staff). These (staff), who have no training in triage (assessment of urgency) and do not follow written protocols, decide on their own whether an inmate may see the doctor the next day. The process means that an inmate may have to wait days before she can get any medication of any kind - even a simple aspirin. The consequences are much more serious for inmates with severe medical conditions [ US Department of Justice "Notice of findings from investigation of Julia Tutwiler Prison for Women," March 27, 1995.].
In 1998, prisoners, lawyers and others told Amnesty International of cases where non-medical staff delayed calling for medical assistance for prisoners because they did not think immediate attention was warranted. Annette Romo, whose letter appears at the beginning of this chapter, is one of these.Charges for medical attention
In violation of international standards, which require free medical treatment for people in custody, many prisons and jails charge inmates for medical attention [ In a recent survey of prison authorities, 27 states reported that they charge inmates for some forms of medical attention, 11 reported that they do not charge and 2 reported that they were considering charging. The charge varies between $2 and $5 and the circumstances in which inmates are charged vary: "Inmate Health Care, Part I," Corrections Compendium, October 1998. There is no similar data on the number of jails that charge.]. In California, for example, prisoners are required to pay $5 in order to receive attention from a doctor, nurse or dentist. There are exemptions for specified circumstances (e.g. follow-up treatment, chronic conditions, mental health) and for prisoners who do not have money to pay the fee. Authorities argue that the imposition of charges is a reasonable measure to deter prisoners from seeking medical attention unnecessarily, for example for minor matters or because they want to avoid work. But charges may also deter poor prisoners from seeking help for what might be serious matters. Prisoners interviewed by Amnesty International said that the payment requirement is a significant deterrent for women who have a small amount of money. Following an investigation of a supermaximum prison in Maryland, where prisoners cannot work at all, the US Justice Department expressed concern that charging prisoners impeded their access to health care [ US Department of Justice letter of findings of investigation of Maryland Correctional Adjustment Center, 1 May 1996.].
Commercial companies providing health services
In some states, private companies have been contracted to provide prison health services. According to reports, some investigations have found that inmates have died because essential medical services were restricted in order to save money. For example, in 1996 Melody Bird, an inmate in Pinellas County Jail, Florida, complained of serious chest pains and difficulty in breathing. Nurses at the jail believed she was having a heart attack but were not permitted to call for an ambulance to take an inmate to hospital without prior approval from the medical director of the company contracted to provide health care services at the jail. They contacted the medical director but did not receive permission to call an ambulance for thirteen hours. Melody Bird died before reaching the emergency room. After her death, it is reported, "company nurses came forward to say that they had been pressured to avoid sending inmates to the emergency room because of the expense." As well, it was discovered that the company sometimes paid the medical director bonuses to keep inmates out of the emergency room [ The account of Melody Bird's treatment is in M Petersen, "Managed Health Care in Prisons Gains Favor, but Draws Concern," New York Times, 26 December, 1996. See also, for example, "Death, Neglect and the Bottom Line," St Louis Post-Dispatch, 27 September, 1998, an investigation into Correctional Medical Services Inc, reportedly the largest private health care provider in US prisons and jails; "Suicide in Jail Leads County To Cancel Pact," New York Times, 20 June, 1996; A Lomax, "Managed Care Infects Prison Health Services," Prison Legal News, volume 8, Number 10, October 1997. ]. Some authorities have reportedly ended contracts with private companies because of concerns about the quality of their services.
Recommendations to ensure adequate health care
Reports received by Amnesty International indicate that many incarcerated women in the USA do not have access to the physical and mental health care to which they are entitled under international standards. The provision of such services is vital for the health of these women and for their rehabilitation. Amnesty International therefore recommends the following measures:
* Local, state and federal authorities should provide resources to enable jails and prisons to identify the physical and mental health care needs of all inmates upon admission and while they are in custody and to provide necessary services and treatment.
* Health care should be provided without charge.
* Health care to women in custody should accord with professionally recognized community standards for services to women.
* Authorities should establish standards of adequacy and appropriateness for jail and prison physical and mental health services and conduct periodic, external reviews of the services.
* People suffering severe mental illness should be housed and treated in mental health institutions and not in jails and prisons.
* The federal government should establish an inquiry into mental health services for women in jails and prisons. One element of the study should be the use of psychotropic medication.
VIII SUPERMAXIMUM SECURITY FACILITIES
In the past few years, many US states have built "super-maximum security" (or "supermax") facilities designed to house prisoners in long-term isolation in particularly restrictive conditions. Sometimes entire prisons are designated supermax facilities; others are units within prisons [ The names given to such units vary; many are called "Security Housing Units" (SHUs). Although the term "supermax" is not the official term given to all such units, it has become a generic term used by experts in the field (and by the National Institute of Corrections in a 1997 survey) to describe high security facilities designed to manage or control inmates considered (on security or disciplinary grounds) to require maximum restrictive custody arrangements.]. Prisoners in these facilities may be confined for nearly 24 hours a day in sometimes windowless cells with solid doors, with no work, training or other programs. The facilities are designed to minimize contact between staff and inmates, and prisoners are often subjected to regimes of extreme social isolation and reduced sensory stimulation. The length of time inmates are assigned to such units varies, but some prisoners spend years, or even their whole sentence, in isolation.
The large majority of prisoners in supermax units are men. However, several states have constructed similar facilities for women prisoners [ There appears to be no comprehensive national data on female inmates in US supermax facilities. A telephone survey of 20 states with substantial female inmate populations conducted by Amnesty International in January 1999 suggested that, while most had some administrative or disciplinary segregation cells for women, only a few had constructed units which appeared to fit the "supermax" category for long-term confinement. States which had such facilities included Arizona, California, Colorado, Oklahoma and Mississippi. Women under sentence of death were also held in some of these units.]. As well as harsh physical conditions, the operation of some high security units for women violates standards on privacy and human dignity, as the women are able to be observed at all times by male guards. The isolated nature of these units may increase opportunities for abuse.
Amnesty International believes that conditions in many US supermax facilities violate international standards for the humane treatment of prisoners and exceed what is necessary for security purposes [ Some conditions violate specific standards under the UN Standard Minimum Rules, which require, for example, that prisoners should have adequate access to natural light and fresh air; to daily exercise; and to educational, recreational, and rehabilitation programs.]. Both the UN Human Rights Committee and the UN Special Rapporteur on Torture have expressed concern about conditions in such facilities [ See HRC Comments of 6 April 1995, UN Doc. CCPR/C/79/Add.50, and UN Doc. E/CN.4/1996/35].
Studies have shown that prolonged isolation in conditions of reduced sensory stimulation can cause marked psychological and physical harm. Health experts who have examined prisoners in isolation have documented symptoms including acute anxiety and panic attacks, hallucinations, sudden violent outbursts, self-mutilation, difficulty with concentration and memory, deteriorating vision, and weight loss [ See, for example, S. Grassian: Psychopathological effects of solitary confinement, American Journal of Psychiatry, 140, 1450-1454 (1983)). These and other symptoms have been demonstrated in the case of inmates in modern US supermax units, such as the Pelican Bay Security Housing Unit (SHU) in California (see Madrid v Gomez 889 F. Supp. 1146, N.D.Cal.1995). See also Amnesty International: UK Special Security Units - Cruel, Inhuman and Degrading Treatment, 1997, AI Index: EUR 45/06/97 (a report describing how UK prisoners held in similar conditions in Britain were found by doctors to have suffered symptoms including headaches and stomach pains, muscle wasting, anaemia, deteriorating vision and memory, and anxiety symptoms).].
Even small group isolation can be damaging, especially when accompanied by other measures. Three women convicted of politically motivated offences were transferred to a High Security Unit (HSU) in Lexington Federal Penitentiary, Kentucky, in the 1980s. Their mental and physical health was found to have seriously deteriorated after about a year in a highly restrictive and sterile environment in which they had limited association with up to four other inmates [The findings were documented in a lawsuit brought by the National Prison Project of the American Civil Liberties Union, and described in an Amnesty International Report USA: The High Security Unit, Lexington Federal Penitentiary, Kentucky (AMR 51/34/88). None of the women had any record of disciplinary offences or escape attempts while in prison but were placed in the unit on the grounds that their affiliations to outside groups (including, in one case, the Puerto Rican independence movement) could lead to rescue attempts being made on their behalf. Amnesty International said it considered that the conditions of their confinement and their assignment to the unit on grounds of their political affiliations constituted "cruel, inhuman and degrading treatment." The women were later transferred to other prisons where they were held in less restrictive conditions.]. The physical conditions in the Lexington HSU, which has since been closed, were superior in many respects to those found in many supermax units today (HSU cells, for example, were larger than average and there was recreational equipment in a day room). Some of the more oppressive conditions in HSU - constant surveillance, lack of privacy, the use of restraints and frequent strip searches - continue to be found in some high security units for women.
The US authorities have defended the use of supermax facilities as being necessary to control extremely violent or disruptive prisoners. However, many inmates assigned to high security units do not appear to fit these criteria, or to warrant such an extremely punitive environment. For example, some prisoners have been sent to such units for repeated minor rule violations. In many states, mentally ill or disturbed prisoners are held in supermax units, despite evidence that the conditions are likely to exacerbate their disorders and lead to psychosis [ Some US courts have ordered the removal of mentally ill inmates from specific supermax units on these grounds, e.g. the federal district court in Madrid v Gomez (op cit) ordered the removal from the Pelican Bay Security Housing Unit (California) of mentally ill inmates "who the record demonstrates are at a particularly high risk for suffering very serious or severe injury to their mental health..." It defined such inmates as "the already mentally ill, as well as persons with borderline personality disorders, brain damage or mental retardation, impulse-ridden personalities, or a history of prior psychiatric problems or chronic depression."]. According to prison experts, mentally ill prisoners are often more likely than other inmates to end up in such units because of behavioural problems and because prisons lack adequate mental health treatment programs. Women prisoners, especially, rarely fit the criteria most commonly given by the authorities for justifying such units (a history of prison gang-related activities, escapes or violent assaults).
Although few recent studies have been undertaken of women in supermax facilities, the evidence in some states bears out the above concerns. A 1996 survey of 14 women held in a special unit in Colorado State Penitentiary (CSP), an otherwise all-male facility, found that 11 of the women were serving sentences for minor, non-violent felonies such as theft, forgery and substance abuse [ Survey undertaken by the Prisoners Rights Project at the Rocky Mountain Peace and Justice Center, Boulder, Colorado.]. Many of them had been sent to CSP for relatively minor disciplinary infractions and were mentally ill or had histories of mental illness. Yet their conditions were extremely punitive and included 23-hour cellular confinement, with solitary exercise taken in a small cell equipped (like those in the men's units) with only with a chin-up bar bolted to the wall. No outdoor exercise was provided. The shower unit had glass windows which exposed the women to the view of the predominantly male guards[ In January 1999 all female inmates in CSP were transferred to the Denver Women's Correctional Facility where they continued to be held in isolation.]. The Security Housing Unit in Valley State Prison for Women, California, raises similar concerns, outlined below.
The Security Housing Unit (SHU), Valley State Prison, California
In November 1998, an Amnesty International delegation visited the SHU in Valley State Prison for Women (VSPW) and spoke to staff and inmates [Amnesty International's delegates were Dr Silvia Casale, a prison consultant and UK member of the European Committee for the Prevention of Torture, and two staff members of Amnesty International's International Secretariat. Amnesty International was given access to all parts of the prison and was allowed to interview individual prisoners in private, as well as talk freely to inmates and staff during their tour. At the time of writing, Amnesty International was preparing its detailed findings and recommendations to the California Department of Corrections on various aspects relating to the operation of VSPW.]. The SHU is situated, with the Administrative Segregation unit, in a separate block within the prison complex. It is the highest security unit for female prisoners in California, housing prisoners from across the state who are classified as a "threat to safety or security." Forty six women were confined in the unit at the time of the visit, most in cells by themselves [The SHU has 44 cells with two concrete bunks for potential double-occupancy. The SHU is next to the Administrative Segregation Unit (Ad-Seg) where the conditions are similar, and where 63 women were detained at the time of Amnesty International's visit. Prisoners are generally held in Ad-Seg pending hearings into alleged serious misconduct (including SHU hearings) or criminal investigations. They may also be sent to Ad-Seg for up to ten days for less serious disciplinary offences. SHU terms may only be imposed following a hearing by the Institutional Classification Committee (ICC). Anyone in Ad-Seg must have their custody reviewed every 30 days.]. Most prisoners are assigned to the unit for disciplinary offences carrying determinate SHU terms; inmates may also be sent to the unit for indeterminate periods because of general behavioural problems. Consecutive sentences may be imposed for misconduct while in the unit, which can considerably extend time served in the SHU. More than half the women in the SHU in November 1998 were serving SHU terms of a year or more, some for apparently minor breaches of discipline (see below) [ These sentences ranged from 12 to 54 months in one case (SHU roster of November 19, 1998).]. Inmates could accumulate SHU terms long enough to spend their entire sentence in the unit [ The SHU terms could be extended up to a "maximum" release date which is the date at which the inmate is due to be discharged from prison on serving her prison sentence.].
Unlike the general population at VSPW, the inmates have no work, education or other programs and are locked in small concrete cells for 22-24 hours a day. The narrow windows at the back of each cell are frosted over so there is no view of the outside. The cells have solid steel doors, cutting off contact with other inmates, with a window through which the guards can view the prisoners at any time. The women take all meals in their cells and are generally allowed out only for 15-minute showers, non-contact visits and exercise (alone or in small groups) in a bare yard surrounded by high walls. SHU inmates are allowed a limited number of possessions in their cells, including a radio and TV which they must purchase themselves. No clocks or watches are allowed.
The security measures are stringent and follow statewide rules designed originally for high security units in maximum security prisons for men. All custody staff are required to wear special protective (stab-proof) jackets while escorting the prisoners or patrolling the unit. The psychiatric and medical staff also voluntarily wear protective jackets if they need to talk to prisoners at their cell doors, even though the women are locked inside. Armed guards oversee the exercise yards and the control booth inside the unit. The women are placed in mechanical restraints [ The women are handcuffed behind their backs while being escorted within the SHU, and are required to wear handcuffs and waist chains outside the unit, e.g. during visits. One inmate told Amnesty International she had been required to wear leg shackles for two months whenever she left her cell, including for showers and exercise, after she had attempted to kick an officer. Bruising around her ankles, consistent with shackling, was still visible at the time of the interview.] and strip searched every time they leave their cells; they are also strip searched again after returning from visits and the exercise yard.
Amnesty International considers that many aspects of the security procedures imposed in the unit are oppressive and go beyond what is appropriate or necessary for the population confined there. Some of the procedures breach international standards on human dignity and privacy and are open to abuse. For example, the rules require that SHU inmates be "in full view" at all times and they are not allowed to cover their cell windows, even when using the toilet in their cells. Some prisoners have complained that male guards peer at them while they are on the toilet or undressing. Prisoners told Amnesty International that some women deliberately expose themselves to male guards for extra provisions and that several guards have encouraged this.
The showers are in an area in full view of the custody staff and have only small panels to cover the middle part of the prisoners' bodies. Male guards have been removed from the control booth following complaints that they could see into the showers from this position. However, women taking showers can still be observed by male guards in the unit itself [Two of Amnesty International's delegates were in the central floor of the unit while several women were showering on the tiers above, and noted that the "modesty" panels did not protect all women from exposure of their buttocks and genital area, especially those taking showers on the upper tier.].
The constant exposure and lack of privacy has reportedly contributed to severe stress in some cases; some prisoners said they found the constant strip searches stressful and humiliating and, although they were conducted by female guards, male guards were often standing nearby. One woman said she had not taken exercise during four months in the SHU because she did not want to undergo the strip searches before and after each visit to the yard.
Amnesty International raised concern about the SHU conditions at a meeting with the California Department of Corrections following its visit to VSPW. The prison authorities said that the conditions were deliberately severe in order to deter inmates from repeated, serious rule violations. They also said that the security measures were necessary to protect both staff and prisoners from the small percentage of highly assaultive and predatory inmates in the system.
However, the records indicate that some women are assigned to the SHU, or have had their stay extended, for relatively minor offences. For example, several women had received long consecutive SHU sentences for acts such as spitting at a guard, or issuing a verbal threat [Although the SHU roster showed that a significant proportion of women were serving SHU terms for offences such as "battery" or "assault" on an officer or inmate, these included such acts as "gassing" (throwing liquid, which could include urine, a cold drink or an unknown liquid) or "spitting." One woman received an 18 month consecutive SHU term for "spitting" at a guard and blocking her toilet; this was later reduced to 9 months.]. Some had lost "good conduct credits" (thus extending their stay still further) for covering up their cell windows. Officials told Amnesty International that an inmate's stay on the unit could be extended if she "acts out" (misbehaves).
A significant proportion of women in the SHU also suffer from mental health problems which may make it particularly difficult for them to cope with the conditions imposed. Some have histories of sexual and physical abuse, depression, and attempted suicide. Amnesty International was told that all prisoners undergo a mental health evaluation by the prison mental health staff before being sentenced to a SHU term. However, in practice it appears that only acutely ill prisoners qualify for exclusion, or removal, from the SHU. Many of the women in the SHU are in the prison's "clinical case management system" for mental health problems, for which treatment is largely confined to the prescription of psychotropic drugs [The Quarterly Management Report for VSPW shows that, in October 1998, 546 prisoners out of a total VSPW inmate population of 3,676 were identified as "CCCMS" (Correctional Clinical Case Management System), meaning that they had been diagnosed as suffering from various forms of mental disabilities requiring monitoring and treatment. Amnesty International was told that more than half the SHU inmates were designated as CCCMS.]. Other treatment, such as individual or group therapy, was unavailable due to lack of resources [Some limited counselling services were available to a few inmates.].
The prison psychiatrist told Amnesty International that any inmate suffering from a mental health crisis, such as psychotic decompensation (or breakdown), would be transferred to the Emergency Out-Patient (EOP) unit in a neighbouring prison. However, Amnesty International is concerned about the adequacy of the monitoring of SHU inmates for mental health. After the initial screening, there is no regular examination of each inmate by the psychiatric or other qualified mental health staff and the system appears to relies primarily on self-referrals by inmates or referrals by custody staff and health technicians [Officials told Amnesty International that custody staff, including medical and psychiatric technical assistants, do daily rounds and ask inmates through the cell doors if they are OK. However, inmates who are mentally ill may not necessarily seek help. Some inmates told AI they were not seen by psychiatric staff despite requests and complaints that they felt "stressed out".] This falls short of international and US professional correctional health care standards [The National Commission on Correctional Health Care (NCCHC) standards require that inmates in administrative segregation should be evaluated by qualified health personnel at least three times a week, and prisoners in disciplinary segregation should be seen daily (Standards for Health Services in Prison, 1997, pages 45 and 53). Rule 32(3) of the UN SMR requires prisoners in close confinement to be visited daily by the medical officer to assess their physical and mental health.]. According to inmates and their attorneys, many of the women are reported to have deteriorated while on the unit, crying or shouting uncontrollably, banging their heads against the cell walls, or committing acts of self-mutilation [One of the women interviewed by AI was reportedly in the SHU for repeated acts of cutting, and had made several suicide attempts for which had been transferred at various intervals to a quiet room, or observation cell, then returned to the SHE - when AI mentioned this to a senior staff member, she said that she would be removed from the SHE when her behaviour changed.].
Recommendations on Supermaximum Security Facilities
* The state, federal and prison authorities should urgently review their criteria for confining prisoners in supermax units; they should amend their policies to ensure that no prisoner is required to be confined long-term in conditions of isolation and reduced sensory stimulation.
* The authorities should immediately improve conditions in such units so that prisoners receive more out-of-cell time, improved exercise facilities and adequate access to natural light and fresh air.
* Security measures should be conducted in a way that does not violate standards requiring that prisoners be treated with respect for human dignity.
* Inmates who are mentally ill or disabled, or at risk of mental illness, should not be placed in supermax units. All prisoners in disciplinary or administrative segregation should have their physical and mental health regularly evaluated by qualified health personnel in accordance with professional health standards, and should receive adequate treatment.
IX SUMMARY OF RECOMMENDATIONS
Recommendations relating to international commitments
The USA's reluctance to fully accept international human rights treaties and standards denies women in the USA rights and protections which many other governments around the world have agreed to recognise. Amnesty International recommends that the USA should:
* ratify without reservations the human rights treaties that it has not yet ratified and in particular the Convention on the Elimination of All Forms of Discrimination Against Women, the Inter-American Convention on the Prevention, Punishment and Eradication of Violence against Women and the American Convention on Human Rights;
* withdraw its reservations to the International Covenant on Civil and Political Rights, the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment and the International Convention on the Elimination of All Forms of Racial Discrimination;
* give people in the USA recourse to international human rights protection mechanisms;
* submit to the international monitoring bodies the USA's overdue reports on its implementation of the Convention against Torture and the Convention on the Elimination of All Forms of Racial Discrimination.
Recommendations to protect female inmates from sexual abuse
Amnesty International considers that the nature and extent of sexual abuse of female inmates by male staff in jails and prisons in the USA, and the harm that sexual abuse causes, warrants strong and immediate action by authorities responsible for jails and prisons to provide the protection to which incarcerated women are entitled under international standards. Amnesty International calls upon authorities to publicly recognise that sexual abuse constitutes torture or cruel, inhuman or degrading treatment or punishment and to take the following measures to combat it:
* Female inmates should be guarded only by female officers. Male staff who provide professional services in female facilities should always be accompanied by female officers.
* Sexual abuse of inmates by staff should be expressly prohibited and action taken against staff who sexually abuse inmates.
* Sexual abuse should be widely defined to include sexual assault and threatened sexual assault; sexual contact; and sexually explicit language and gestures.
* All staff and inmates should be informed that sexual abuse is prohibited and that
* inmates have a right to complain if they are abused.
* staff have a duty to report if they know that an inmate has been abused.
* All complaints must be investigated independently, promptly and thoroughly in line with best practice for the investigation of sexual assault.
* Victims of sexual abuse must be provided with appropriate care and redress.
* Inmates and staff who report abuses should be protected from retaliation by measures including:
* inmates and staff must be informed that they have a right to protection from retaliation;
* as far as practicable, reports of abuse by inmates and staff should be treated in strict confidence;
* disciplinary and/or legal action, as appropriate, should be taken against any member of staff who seeks to deter inmates and staff from reporting abuse or who, in any manner, harasses or intimidates inmates or staff who report abuse.Recommendations on the use of restraints
In prisons and jails around the USA, restraints are commonly used when they are not essential to prevent escape or to protect people and property. This is particularly evident in cases of women who are in labour or who have just given birth, or who are seriously ill. The use of restraints in these circumstances violates international standards that prohibit the imposition of torture and other forms of cruel, inhuman and degrading treatment and punishment.
Amnesty International recommends that jails and prisons should adopt policies on the use of restraints that accord with international standards, as follows.
* Restraints should be used only when they are required as a precaution against escape or to prevent an inmate from injuring herself or other people or damaging property. In every case, due regard must be given to an inmate's individual history.
* Policies on the use of restraints should prohibit their use on:
* pregnant women when they are being transported and when they are in hospital awaiting delivery
* women who have just given birth
* seriously sick inmates when they are being transported to and when they are in hospital.
* Policies on restraints should specify that the types of restraints and the circumstances of their use must not be hazardous to the health and safety of inmates.
* The use of restraints should be monitored to ensure strict compliance with policies.
Recommendations to ensure adequate health care
Reports received by Amnesty International indicate that many incarcerated women in the USA do not have access to the physical and mental health care to which they are entitled under international standards. The provision of such services is vital for the health of these women and for their rehabilitation. Amnesty International therefore recommends the following measures:
* Local, state and federal authorities should provide resources to enable jails and prisons to identify the physical and mental health care needs of all inmates upon admission and while they are in custody and to provide necessary services and treatment.
* Health care should be provided without charge.
* Health care to women in custody should accord with professionally recognized community standards for services to women.
* Authorities should establish standards of adequacy and appropriateness for jail and prison physical and mental health services and conduct periodic, external reviews of the services.
* People suffering severe mental illness should be housed and treated in mental health institutions and not in jails and prisons.
* The federal government should establish an inquiry into mental health services for women in jails and prisons. One element of the study should be the use of psychotropic medication.
Recommendations on Supermaximum Security Facilities
* The state, federal and prison authorities should urgently review their criteria for confining prisoners in supermax units; they should amend their policies to ensure that no prisoner is confined long-term in conditions of isolation and reduced sensory stimulation.
* The authorities should immediately improve conditions in such units so that prisoners receive more out-of-cell time, improved exercise facilities and adequate access to natural light and fresh air.
* Security measures should be conducted in a way that do not violate standards requiring that prisoners be treated with respect for their privacy and human dignity.
* Inmates who are mentally ill or disabled, or at risk of mental illness, should not be placed in supermax units. All prisoners in disciplinary or administrative segregation should have their physical and mental health regularly evaluated by qualified health personnel in accordance with professional health standards, and should receive adequate treatment.