Women's Health in Prison in the Northern Dimension Area

Northern Dimension Partnership in Public Health and Social Well-being

NDPHS Expert Group on Prison Health

Thematic Report

Women’s Health in Prison in

the Northern Dimension Area

NDPHS Series No. 3/2008

Northern Dimension Partnership in Public Health and Social Well-being (NDPHS)

NDPHS thematic report: Women’s Health in Prison in the Northern Dimension Area

The views reflected in this paper are those of the members of the NDPHS Expert Group on Prison Health who have developed it and should not, therefore, be interpreted otherwise. If specific country data are not available in this report, this is because the authors were either unable to obtain it or did not receive permission to publish this data.

Editors: Ingrid Lycke Ellingsen, Elo Kocys and Maxi Nachtigall Pictures: Juerg Christandl, Amy Allock Maps: NDPHS, Nordic Council of Ministers

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It is also available on-line in the Papers’ section of the NDPHS Database at http://www.ndphs.org/?database,view,paper,19

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The paper arises from the project “NDPHS Project Database” which has received funding from the European Union, in the framework of the Public Health Programme. The sole responsibility for that document lies with the NDPHS Expert Group on Prison Health. The Public Health Executive Agency is not responsible for any use that may be made of the information contained therein.

1 CONTENTS

I. Executive Summary

1. INTRODUCTION……………………………………………………………………………….05 1.1 Women in Prison - a vulnerable group……………………………………...... 08 1.2 Background…………………………………………………………………...... 09 1.3 Gender Equality in Prison Health………………………………………...... 10 1.4 Report guidelines…………………………………………………………………………..10 1.5 Expected outcomes………………………………………………………...... 12

2. LEGAL BACKGROUND...... 13 2.1 Legal background of health services in prisons……………………… …...... 13 2.2 Regulations on women’s health in prison…………………………… …...... 16 2.3 Regulations on work and education in prisons……………………… …...... 20

3. WOMEN’S HEALTH IN PRISON IN THE NORTHERN DIMENSION AREA…………………………………………………………………………………………….23 3.1 The prison health situation in the ND area………………….…………………………..23 3.2 Female prisoners in the ND area………………….……………………...... 26 3.2.1 Age……………………………………………………………………...... 28 3.2.2 Organization of medical service within penitentiaries in the ND area…………….…………..….…………………………………………….28 3.2.3 In practice within the ND area: General Health...…..……….……………….29 3.3 Main health problems encountered by women in ND area prisons ………………….30 3.3.1 HIV/AIDS…………………………………………………………...... 30 3.3.2 HIV positive pregnant women in prison.………………………………………33 3.3.3 In practice within the ND area..………………………………………………...34 3.4 Tuberculosis (TB)……………………………………………………………...... 36 3.4.1 In Practice within the ND area: TBC/ HIV...……………………...... 38

4. PREGNANT WOMEN AND MOTHERS IN PRISON…………………………...... 40 4.1 Pregnant women in custody………………………………………………...... 41 4.1.1 Women in prison who are accompanied by their children ……………………...42 4.1.2 In practice within the ND area...……………………..………………...... 44 4.2 Women with children outside the prison – social well-being and prevention measures……………………………………………………………………...... 47 4.2.1 In practice within the ND area..………………………………………………...51 4.3 Criminal behaviour of youths………..…………………………………...... 52

5. SOCIAL REHABILITATION AND PRE-RELEASE TRAINING……………...... 55 5.1 Background…………..………………………………………………………...... 55 5.2 In practice within the ND area: Estonia – a case study...……………...... 59 5.2.1 Individual Sentence Plan………………………………………...... 59 5.2.2 Employment……………………………………………………………………...59 5.2.3 Education in prison……………………………………………………………...60 5.2.4 Rehabilitation Programmes……………………………………...... 61 5.2.5 Preparation for release…………………………………………...... 62 5.2.6 Anger management………………………………………………...... 63 5.3 VINN (WINNING) a good practice in social rehabilitation from Norway……………..65 5.4 NGO’s involvement………………………………………………………………………...66 5.4.1 In practice within the ND area..…………………………….…………………..67 5.5 Alternative measures to prisons for non-violent offences:……………………………..70 5.5.1 In practice within the ND the area...…………………………………………...71

6. RECOMMENDATIONS…………………………………………………………...... 73

Appendix I List of references………………………………………………………...... 76

Appendix II Questionnaire……………………………………………………………...... 86 Appendix III Index of Tables and Maps…………………………………………………………….89

3 I. EXECUTIVE SUMMARY

In the countries of the Northern Dimension (ND) area, the penal system presents a section of the society where major health problems are concentrated. For those who have to spend a shorter or longer time, or even a life-time, in prison, aspects of prevention and treatment for many complicated health problems become as crucial as the provision of rehabilitation and reintegration programmes for inmates, which are intended to help them ease back in society after their release. The spread of communicable diseases occurs predominantly between persons from marginalised groups who that live under harsh socio-economic circumstances, and consequently, many of which enter the penal system.

There are also obvious connections between social disparities, mental health problems, drug use, infectious diseases, crime and imprisonment. Thus, it is necessary to extend the scope of joint work concerning penal systems in the Northern Dimension area to cover not only communicable diseases but also prevention and the better treatment of psychiatric disorders, the treatment and rehabilitation of drug addicts, improved custodial conditions for inmates, training for prison staff and strengthened co-operation between the prison system and the civil and social services in general. Female prisoners, and among them, women who are pregnant or caring for small children, constitute an extremely vulnerable group within the prison population. Therefore, this Thematic Report will focus especially on challenges faced by this group.

Taking the health issues of women in prison into account, this Thematic Report developed by the Northern Dimension Partnership in Public Health and Social Well-being (NDPHS) Expert Group on Prison Health (PH EG) will examine how women’s health in prison is organized and whether health care and social well-being in prison is being adequately adjusted to women’s needs. It seeks to give recommendations to implement gender equality in the field of prison, including in the approach and assessment of prison health services.

CHAPTER 1

INTRODUCTION

Photo by Juerg Christandl

“It is a fundamental human right of everyone, including prisoners to the enjoyment of the highest attainable standard of physical and mental health. The state has a particular responsibility towards prisoners, as their loss of liberty means that the primary responsibility for their health then falls on the prison administration. Not only do prison authorities have a responsibility to provide medical care, they must also establish conditions which promote the well-being of prisoners and staff. Prisoners should not leave prison in a worse condition than when they entered.” (OHCHR 2006)

In the countries of the Northern Dimension (ND) area, as in all other countries, the penal system presents a section of the society where major health problems are concentrated. “The obvious purpose of a prison sentence is to punish the offender and to prevent her/ him from re- offending” (NDPHS Working Plan 2007-2008). However many former prisoners return to committing crimes after being released, creating a vicious circle of punishment and re-offence. For those who have to spend a shorter or longer time, or even a lifetime, in prison, aspects of prevention and treatment for many complicated health problems become as crucial as the provision of rehabilitation and reintegration programmes for inmates, which are intended to help them ease back into society after their release. The spread of communicable diseases occurs predominantly between persons from marginalised groups who live under harsh socio-economic circumstances, and consequently, many of which enter the penal system. There are also obvious connections between social disparities, mental health problems, drug use, infectious diseases, crime and imprisonment. Thus, it is necessary to extend the scope of joint work concerning penal systems in the Northern Dimension area to cover not only communicable diseases but also the prevention and better treatment of psychiatric disorders, the treatment and rehabilitation of drug addicts, improved custodial conditions for inmates, the training of prison staff, as well as the strengthened co-operation between the prison system and the civil and social services.

“With an ever increasing inmate population, prisoners are typically classified by security level or medical and psychiatric needs. Gender is another key category” (Desrosier & Senter 2007:7). Nearly all international instruments relating to the rules and standards of imprisonment (see chapter 2) refer to female prisoners as a minority group whose special needs are to a large degree ignored by all states, and accordingly, also by the states within the Northern Dimension

5 area. Therefore, the issue of gender equality also needs to be raised in terms of female imprisonment, in order to fight gender discrimination within prison regimes. There is also a need to make positive adjustments to conditions for women detainees in terms of staff, accommodation, education and training, and last but not least, in terms of health.

In general, people who are in prison need a high level of health and social care (Hayton 2007, 18-19). Women are a minority in prisons but they are one of the most vulnerable groups when it comes to health issues and healthcare settings. As males comprise the majority within the prison population, women’s special needs are often neglected. Their rights as prisoners are for the most part ignored or badly implemented. But many health and social issues relating to imprisoned women could be solved by properly implementing rights and regulations that already exist (Kurtén-Vartio 2007).

The majority of the women in prison are first time offenders and many of them are never sentenced, but are rather kept on remand for a short period of time. Furthermore, most of female detainees are not accused for violent offences but mainly for the non-payment of fines, theft, prostitution and drug-related offences.1

Women are mainly accused of crimes leading to convictions that are short in duration or only kept in pre-trial detention for a limited amount of time. As a consequence, they might often be suddenly and unexpectedly released. Therefore, they cannot profit from any health or social rehabilitation programmes, as those programmes are mainly created for prisoners whose prison sentences are longer than one year. Meanwhile, a considerably higher number of women than men in custody have substance abuse problems, which will require long-term treatment.

The Quaker Council of European Affairs states that: “Unlike most male prisoners women do not have someone on the outside holding onto the family home and possessions and caring for their children. Women suffer disproportionately from being held far from their families and being separated from their children, receiving fewer visitors than men. Women are often lone-carers and we are concerned about what happens to children and elderly relatives in need of care. We notice the poverty in most prisoners’ families and that poverty usually increase with imprisonment” (http://www.quaker.org/qcea/prison/index.html). Many babies and children are separated from their mothers due to the imprisonment of the mother. The United Nations Office on Drugs and Crime (UNODC) estimates that around 100, 000 women are detained in prisons across Europe: “The Howard League for Penal reform, a non-governmental organisation estimated that around 10,000 babies and children aged under two are affected by the this situation (UNODC 2007a:14)”.

“Due to their small numbers women often have less access to services than men. Their security regimes are often disproportionately harsher than men’s because there are not enough women to make up separate blocks. Women’s health care needs such as ante-natal care are often overlooked, as are their needs to combat drug-addiction and treat mental health problems. Female prisoners have a higher rate of mental illness and are more likely to have been victims of physical and sexual abuse than the general population. Women have high rates of suicide and self-harm in prison” (http://www.quaker.org/qcea/prison/index.html). An exceptionally vulnerable group in prisons includes pregnant detainees and female detainees who are accompanied by their children.

Women who are detained in prison over long periods of time will have a greater demand for health services. Their medical problems are more complex and the fact that females have

1 Anti-social behaviour among females that often leads to minor, non-violent crime is typically the result of past trauma, such as physical and emotional abuse, poverty, and childhood brutality, neglect or victimization. Therefore, it should be recommended that every woman who is entering prison for the first time receive a social background screening.

6 particular health issues should also be taken into account. Imprisoned women place heavy demands on staff, requiring frequent and at least regular meetings with doctors/nurses. Still, female detainees cannot be characterised on the whole as being sicker than male prisoners are. Having access to regular professional healthcare, females utilise this resource more frequently than their male counterparts. Additionally, women are sometimes looking for health treatment and social care programmes in order to keep or regain the custody of their child/ children, or their right to visit their child and extended family. Women who are sentenced to prison have in many cases neglected their own health in the past, and thus, their general health conditions are often very poor. Prison might be the only place – and imprisonment the only occasion – in which these particular women are encouraged to accept health examinations and given treatment. Consequently, “prisons can contribute to the health of the communities by helping to improve the health of some of the most disadvantaged people in society” (Fraser 2007:25).

Prison is a microcosm of society in general. It houses however an aggregation of vulnerable individuals most of whom have rather traumatic backgrounds. This is especially the case for females in prison. Compared to male detainees, female inmates are three times more likely to have a history of personal trauma. In this respect, corrective treatment programs should target previous traumatic experiences, including physical, emotional and sexual abuse during both childhood and adult years. Studies have also shown that different forms of abuse early in life lead to self-harming behaviours and/or suicide later in life.

Studies e.g. by the Canadian NGO “Voices for children”2 and the international study on women’s imprisonment by the University of Greifswald (Duenckel at. al. 2005) show that most imprisoned women are coming from broken families or grew up in non-traditional settings such as in orphanages. They subsequently experienced difficulty in leading normal, healthy lives, securing employment, finding a permanent place to live, and building up healthy social networks. It is therefore not difficult to understand why many female prisoners suffer from anxiety, depression, bipolar- and eating disorders, and self-mutilation. Being in custody may cause further stress and generate psychological trauma, especially when women are separated from their partners, children and families. Health care for women in prison must also take into account the negative effects that imprisonment has on any detained individuals. Women, as compared to men, are more prone to self-inflicted harm (also repeatedly).

The withdraw that drug-addicts experience when suddenly brought into custody can lead to acts of self-harm, impulsive, volatile and unpredictable behaviours. Many women face mental health problems, which are often re-enforced by drug dependency.3 An effective treatment for this kind of problem must therefore be a multi-disciplinary, involving psychiatrists, psychologists, social workers and counsellors. This kind of approach “should also include expertise from other non- prison based or community-based organisations with skills and expertise in these areas. This

2 Unlike men, the criminal behaviours of women are typically understood to be part of an overall coping strategy that often have their roots in childhood abuse or neglect, followed by leaving home early, dropping out of school, and substance abuse (as a coping mechanism). Perhaps as a direct consequence, women who are violating laws typically lead lives characterized by poverty, inadequate housing, abusive or exploitative partners, and general instability. Many women in prison left school before graduating, had their first child as a teenager, and have a history of unemployment. They may have few specialized job skills and rely on welfare, low-paying jobs, or criminal sources of income. Even compared to men in prison, women have high rates of serious drug addiction and women with mental health crises can find themselves in prison rather than in more appropriate residential placement. http://www.voicesforchildren.ca/. 3 The WHO publication “Health in Prison. A WHO Guide for the Essentials in Prison Health describes the typical female drug user arriving in prison as being between the ages of 17-30 and having been detained for 7-10 days. These female detainees are often heroin or methadone users, while crack, cocaine, cannabis, alcohol and cigarettes are also abused. These women have a history of drug addiction usually for up to nine years or even longer. Most intravenous drug users are hepatitis C positive, suffer from deep vein thrombosis, abscesses or sexually transmitted infections. They face a lack of information about these diseases. Their partners are mostly also imprisoned;, and their children, if they have any, are placed in extended family care or external care. Many of these women have been subject to a vicious circle of drug addiction and withdrawal, also substituting alcohol or cigarettes for drugs, leading to additional health problems.

7 would provide a high level of ongoing support during and after a woman leaves the prison. In particular, groups with expertise in assisting and supporting women who have experienced sexual assault need to be a part of the team” (Anti Discrimination Commission 2006:89). Many of imprisoned women are non-violent offenders and do not pose a threat to society. They are mainly only a threat to themselves. For the most part, they do not need imprisonment, but rather adequate treatment for their drug and alcohol additions, trauma recovery, education, healthcare, parenting skills and simply better living conditions.4

Special attention must be paid to females’ gynaecological issues, including pre- or postnatal care as well as such care to women with small children. The tasks of prison health staff cannot be limited to treating sick patients only. They must also supervise hygiene conditions (especially for female needs) for catering arrangements; ensure healthy nutrition and diet, and the general living environment in prison.

Taking health issues for women in prison into account, this Thematic Report developed by the NDPHS Expert Group on Prison Health will look at how women’s health in prison is organized and whether healthcare and social well-being in prison is being adequately adjusted to women’s needs. It seeks to offer recommendations to implement gender equality in the field of prison health, including in the approach and assessment of prison health services. Human rights and basic decency should serve as the basis for the promotion of health, because they emphasise all aspects of prison life, especially for vulnerable groups.

1.1 Women in prison - a vulnerable group

As already emphasised, women constitute one of the most vulnerable groups when it comes to health issues and healthcare frameworks:

• There is however a lack of data and information regarding issues on women in prison in general, particularly in health. • Women have often been exposed to additional negative experiences such as mobbing, trafficking, prostitution or abuse. • There are few all-female prisons, which means that women have more challenges to face than men do while in prison. For example, they are often detained far away from their homes and suffer a loss of family ties. They can be victim of social exclusion, unsuitable security classifications, and at risk for cohabitation with male inmates. • There are several minority groups within female prison groups such as juveniles, ethnic minorities, and elderly women, each whose needs are difficult to address. • Women’s healthcare and requirements for social well-being differ from those of men. • Women are at higher risk for self-inflicted harm and suicide.

“Principle 5 (2) of the Body of Principles emphasises in particular that: “Measures applied under the law and designed solely to protect the rights and special status of women, especially pregnant women and nursing mothers, children and juveniles, aged, sick or handicapped persons shall not be deemed to be discriminatory. The need for, and the application of, such measures shall always be subject to review by a judicial or other authority” (Penal Reform International 2001: 94).

4 Some women may have had the possibility to enter into a treatment programme but could not remain in such a programme due to the fact that they are often the only caretakers for one or more children, face inadequate social support systems, and lack the financial resources needed to complete treatment. The judicial system must take these complex issues into account when deciding on the appropriate length of sentences for women. (Anti Discrimination Commission Queensland 2006).

8 On the one hand, the issue of female imprisonment cannot be seen as a highly public issue as imprisonment in general is not broadly discussed in public either. Imprisonment seems to be a sensitive matter for the national authorities in every country. Being active in prison issues or working within the prison regime tends to have a low reputation in the public’s view. One indicator for the rather low relevance of imprisonment in public in general, and of female imprisonment in particular, is the availability of and accessibility to quantitative and qualitative data on issues. But there are differences. Qualitative studies, including field studies and interviews with staff and prisoners are much easier to find than disaggregated statistics on women imprisonment in a certain year or a certain region. On the other hand, it is a strong conviction in the NDPHS Expert Group on Prison Health that the issue of female imprisonment is highly overlooked, mainly in terms of health and social well-being. Far more research should be conducted and published on the living conditions of women in prison in general and their health and social-well being status in particular.

Taking the special situation of women in prison into account, the PH EG is focusing particularly on how prison health for women is organized and how health care in prison is adequately adjusted to women’s needs. As it is important to focus on diseases that affect both genders, there is also a common need to find differences, as to why, for example, certain diseases/problems are more prevalent among women. In order to achieve gender equality among inmates, a comprehensive approach is needed towards prison reform, including the prioritisation of implementing basic human rights. This Thematic Report on women’s health in prison seeks to give recommendations for the implementation of gender equality in the approach to prison health and the assessment of prison health services.

1.2 Background

The Expert Group on Prison Health consists of high-level experts composed by a variety of individuals who are representing different fields of the penal system such as doctors, jurists, social workers and individuals with practical knowledge of working in prisons. They all have considerable experience in working on issues involving communicable diseases and epidemiology, drug abuse and mental disorders.

The PH EG’s overall objective is to promote sustainable development within the penal systems of the Northern Dimension area through improving health and social well-being (NDPHS PH EG 2004). Furthermore, the PH EG aims to:

• Raise awareness and foster commitment from the public regarding health in prisons, in particular for most vulnerable groups such as women, young people, and children. • Work towards the development of positive attitudes towards issues related to health in prison. • Promote networking and partnership-building among relevant stakeholders. • Support coordinated and collaborative efforts to further prison reforms and the development of national policies. • Work towards improving health in prisons in the Northern Dimension area and communicating collective knowledge in the field. • Propose topics and issues for new projects on prison health.

Understanding that good prison health is also good primary health, the Expert Group promotes the standards and rules for good primary health care in prisons and takes this as the foundation of all prison health services.

1.3 Gender Equality in Prison Health

Female prisoners are a minority but a non-deniable group in all national prison regimes. This requires equal opportunities and females’ equal access to social, economic and cultural rights. Up until today, female prisoners have been at a disadvantage in obtaining information about their rights as prisoners, gaining access to vocational and educational training, and adequate health care in prisons. A comprehensive approach to prison is needed that includes elements of implementing of the following basic human rights:

1. Social rights; 2. Economic rights; 3. Cultural rights.

“As prison sentences have been designed for men and by men, women are always an exception. It is a challenge to find special solutions to meet the needs of imprisoned women” (Sonja Kurten-Vartio, 2007). Women in prison settings are considered to be more difficult to deal with than men. Women face more severe moral punishment from society than male prisoners do, meaning that their sense of punishment does not necessarily end after they are released. Instead, their sense of punishment often continues in form of social isolation as well in private and occupational areas of life. On the other hand, searching for health care and social treatment when in prison can be highly valued among inmates. Drug rehabilitation might be an ideal first step in changing detainees’ lives and to give women a perspective for their future outside the prison.

Gender is more than a determinant of health that stands alone, but rather it cuts across all other determinants, namely income and social status, employment, education, social environment, physical environment, healthy child development, personal health practices and culture. The interaction aspects of gender and health can be seen in such factors as poverty, violence, sexually transmitted diseases, mental health, substance abuse, nutrition, health care delivery and reproductive health. Keeping this in mind, the Thematic Report will be based on the notion of gender equality, the process of treating both women and men fairly. “To ensure fairness, measures must be available to compensate for historical and social disadvantages that prevent women and men from otherwise operating on a ‘level playing field’” (Medical Women’s International Organisation 2002:11).5 Gender equality also means that health needs, which are specific to each gender, receive appropriate resources (e.g. reproductive health needs): “Research on women’s pathway into crime clearly suggests that gender matters in the forces that propel women into criminal behaviour and therefore, gender must be taken into account” (Charon Schwartz 2001).

1.4 Report guidelines

During their 3rd Expert Group meeting in Paris in June 2007 and the 5th EG Chairs and ITAs meeting in Vilnius in 2007, the PH EG agreed on the publication of a Thematic Report on women’s health in prison. The topic is also of relevance to a planned conference on women’s health in prison, organized by the World Health Organization (WHO) Europe “Health in Prison Project” (HIPP) in 2008 and a planned publication by WHO on women’s health in prison.

This Thematic Report focuses on the unique situation of women in prisons within in the Northern Dimension area of Europe. It will give a general overview on these women’s situations and will

5 An example of gender inequality is when inmates whose sentences are longer than one year are eligible substance detoxification. This policy is discriminatory towards women as most of the female offenders in need of treatment are generally serving shorter sentences in prison than men.

10 in detail analyse some of their health issues in prison, as “women prisoners physical, mental and emotional needs differ from those of men. Women can have different needs relating to problems such as substance addiction, mental health, anger management and a history of different kinds of abuse” (QCEA 2007:5). This report will pay particular attention to women as a vulnerable and “forgotten” group in prison.

Healthcare in prison must be based upon comprehensive primary healthcare, as “good prison health is good public health” (WHO Europe 2007:2). Therefore this report researches the question of how to provide meaningful primary health care for women in prisons. Primary health care is the foundation of prison health services as it is the “most effective and efficient element of health care in any public health system” (WHO Almaty Declaration 1978). It should be characterised by a balance of disease prevention and health promotion.

As stated by the WHO in its publication “A guide for essentials in prison health” (WHO Europe 2007:26), prison health care services must be able to address four major priorities:

1. Primary care; 2. Mental health; 3. Infections, Tuberculosis (TB), blood borne viruses, including HIV and skin conditions; 4. Dependence, especially on alcohol and drugs.

This Thematic Report framework is based on the following documents:

1. NDPHS PH EG Terms of Reference; 2. Moscow Declaration on Prison Health as a Part of Public Health (WHO Regional Office, 2003); 3. European Prison Rules, revised 2006 by the Committee of Ministers of the Council of Europe (EPR); 4. Standard Minimum Rules for Treatment of Prisoners; 5. Other general international regulations on Prison Health/ Recommendations of relevance; 6. Health in prisons, A WHO guide to the essentials in prison health, 2007; 7. Recommendations of the World conference on women Beijing report 1995; 8. NDPHS founding document, the Oslo Declaration concerning the establishment of a Northern Dimension Partnership in Public Health and Social Well-being.

These documents refer to the obligations of prison authorities to safeguard the health of all prisoners and the “need for prison medical services to be organized in close relationship with the general public health administration” (Coyle 2007:11).

Furthermore, the report will enforce aspects of gender equality within the area of prison health.6 As stated in the WHO Gender policy 2002, “In health, gender analysis contributes to the understanding of differentials between women and men in, for example, risk factors and exposures; manifestations, frequency and severity of disease and social responses to it; access to resources to protect health; and distribution of power and responsibilities in health care.” An underlying theme within the report is a gender approach seeking to deal with the distinct health characteristics of female detainees.

6 Mainstreaming gender is "...the process of assessing the implications for women and men of any planned action, including legislation, policies or programmes, in any area and at all levels. It is a strategy for making women's as well as men's concerns and experiences an integral dimension in the design, implementation, monitoring and evaluation of policies and programmes in all political, economic and social spheres, such that inequality between men and women is not perpetuated. The ultimate goal is to achieve gender equality” (WHO Gender Policy 2002).

11 Accordingly to the Expert Group’s Action plan for 2008, this Thematic Report can form a basis for: • Supporting initiatives for reorienting prison systems to improve the implementation and status of health care; • Revealing gaps in research and action regarding prison health, as well as proposing topics and issues for new project proposals in the field; • Formulating criteria for future support for projects in the field of prison health (this should include the application of a Logical Framework Approach (LFA)); • Increasing the work and visibility of the NDPHS partnership and providing expert input to the preparation and implementation of joint activities carried out within the Partnership framework.

Furthermore, the report has five major objectives. It seeks to:

1. Generate interest from the public in the issue of women in prison; 2. Encourage national authorities, NGOs and national and international organisations to develop projects, and programmes to get involved and active in women’s health in prison; 3. Prompt donor organisations to fund and implement projects in this field; 4. Contribute to the NDPHS database project; 5. Provide a guideline of gender equal treatment in prison health.

Regarding its mandate, the PH EG will research and compile good practice models from prisons across the Northern Dimension Area, addressing the major challenges of women in prison. The report will compile information on policies, projects and programmes as well as recent and ongoing reforms within the prison health area.

This Thematic Report includes results from the PH EG questionnaire, developed by the Editorial Expert Group and disseminated and responded to by some of the members of the Expert Group on Prison Health of each NDPHS member country. As another item, the report gives an overview of the major national and international regulations and written standards concerning prison health in general and women’s health in particular.

The compilation of the report was undertaken by desktop research and the study of publications available on the Internet, from libraries and in archives. Additional input was given by all members of the Expert Group based on their experiences working with women in prison and/or their own studies.

1.5 Expected outcomes

The major outcome of the EG Prison Health Thematic Report will be an outline of the status and recommendations regarding improvement of health and social well-being of women in prison. It will provide good practice models and measurements of good health care for women in prison in the Northern Dimension area. It might serve as a guideline to be of use for authorities and decision-makers in the field of prison health, especially concerning women’s health in prisons. The recommendations should also be used to define core working areas regarding the implementation of the PH EG’s own Work Plan for 2008 and the overall NDPHS Working Plan for 2008 and to identify new project and research areas.

The Thematic Report will be distributed to major stakeholders, decision-makers and members of the NDPHS. It will also be made available to the public on the NDPHS website and broadly disseminated via other NDPHS communication tools.

Chapter 2

LEGAL BACKGROUND

Photo by Amy Allock

2.1 Legal background of health services in prison

The majority of penal institutions resemble organised medical services. The structure, organisation and content vary from country to country as well as what authorities are in charge of the prison medical services. In some countries services are placed under the authority of the Minister of Justice, while in other countries they are under the Minister of Health and Social Affairs. As a third option, there can be joint responsibility over health care in prison. Irrespective of which authorities are responsible for prison health services, they should, if possible, follow the recommendations and guidelines that have been agreed to in principle within international foray.

Such recommendations could include the Moscow Declaration, which was adopted at the joint World Health Organisation/Russian Federation International Meeting on Prison Health and Public Health in October 2003. This Declaration recommends that:

“Member governments [should] develop close working links between the Ministry of Health and the ministry responsible for the penitentiary system so as to ensure high standards of treatment for detainees, protection for personnel, joint training of professionals in modern standards of disease control, high levels of professionalism amongst penitentiary medical personnel, continuity of treatment between the penitentiary and outside society, and unification of statistics.

Member governments are recommended to ensure that all necessary health care for those deprived of their liberty is provided to everyone free of charge.”

Several principal treaties, guidelines and recommendations govern the organisation and content of the prison medical services. An in-depth presentation and overview are to be found in WHO Health in prisons. A WHO guide to the essentials in prison health, which was published in the autumn of 2007. Several prominent authors contributed and the publication offers an almost complete description of different aspects of prison health care. In addition, several chapters contain practical information and advice on how to promote good health in prisons.

This Thematic Report will refrain from re-iterating too many of the facts that have already been discussed in the above mentioned document, however it will concentrate on some important aspects concerning the provision of health care for imprisoned women.

At the outset, some key points which have been expressed by Professor Andrew Coyle in the WHO guidelines: chapter 2, Standards in prison health: the prisoner as a patient should be emphasized:

• People who are in prison have the same right to health care as everyone else; • Prison administrations have a responsibility to ensure that prisoners receive proper health care and that prison conditions promote the well-being of both prisoners and prison staff; • Health care staff must deal with prisoners primarily as patients and not prisoners. • Health care staff must have the same professional independence as their professional colleagues who work in the community; • Health policy in prisons should be integrated into national health policy, and the administration of public health should be closely linked to the health services administered in prisons (this applies to all health matters but is particularly important for communicable diseases).

Documents of particular relevance to prison health care services are The Standard Minimum Rules for the Treatment of Prisoners and the revised version of the European Prison Rules. The latter was adopted in 2006 and contains an elaborated section on prison health care, including information on organisational aspects, medical health care personnel, the duties of medical practitioners, mental health and other matters (Rules 39 – 48):

• Rule 39 states that the authorities’ duty “to provide adequate prison medical services.” Further, that “Prison authorities shall safeguard the health of all prisoners in their care.” • Rule 40.1 states that “Medical services in prison shall be organised in close relation with the general health administration of the community or nation.”

This is consistent with the accepted principle of the Equivalence of care.

The Quaker Council for European Affairs – Women in prison project – has in its document The European Prison Rules: A Gender Critique proposed additions to some of the rules. 7

7 Rule 40: “Prisoners shall have access to the health services available in the country without discrimination on the grounds of their legal situation” and “Prisoners shall have the same choice of health care as the general population.”

The European Prison Rules address of course both genders; however a few rules that are of special interest for the medical treatment of women are cited as follows:

• Rule 40.5 states that “All necessary medical, surgical and psychiatric services including those available in the community shall be provided to the prisoner for that purpose.” 8

• Rule 41 states that “Every prison shall have the services of at least one qualified general medical practitioner”9

The Council of Europe’s Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (The CPT) gives in the Committees 3rd General report (CPT/Inf (93) 12) several recommendations of importance for prison medical services. These recommendations are also published in The CPT standards (www.cpt.coe.int).

The CPT points to the fact that “a well-functioning prison health care service can play an important role in combating the infliction of ill-treatment and make a positive impact on the quality of life in the prisons within it operates. On the other hand can an inadequate level of health care rapidly lead to situations falling within the scope of the term “inhuman and degrading treatment.”

The CPT emphasizes several points that are valid for administrating a well-functioning health care service in prisons:

• Access to a doctor • Equivalence of care • Patient’s consent and confidentiality • Preventive health care • Humanitarian assistance • Professional independence • Professional competence

In the section “Humanitarian assistance”, the CPT mentions certain specific categories of particularly vulnerable prisoners, among them mothers and children. The Committee is of the opinion that special attention should be paid to the needs of these vulnerable groups.

The CPT also recommends several measures concerning ante natal and post natal care which needs to be in place in order to provide satisfactory services to pregnant women and those who are accompanied by their newborn children (published in the 10th General report (CPT/Inf (2000) 13)).

It is important to emphasise once again that prisoners are entitled to the same level of medical care as persons living in the community at large, as this is an inherent, fundamental right of

8 The Quaker Council proposes an addition to this Rule: “All substance abusers shall have access to a rehabilitation programme. Psychiatric services and drug rehabilitation services should be gender-sensitive, e.g. offering women- only therapy groups.” They also propose a new rule, namely: “Prisoners should have adequate access to information regarding their health and health care choices, particularly surrounding addiction and sexual health; female prisoners should have access to information surrounding women’s health issues.” 9 The Quaker Council proposes that Rule 41.1 has the additional wording: “Such a practitioner should have knowledge of women’s physical and health, eating disorders and the psychiatric implications of abuse and domestic violence when employed in prisons where female prisoners are held. General practitioners should understand these implications if they transfer from a male prison to a female or mixed prison.” This is further to Rule 41.5 that “Women prisoners should have the option to see a female doctor on request; they should not have to give reasons for such a request.”

15 individuals. The CPT has frequently received complaints that states cannot provide adequate health care for prisoners because of a shortage of resources. The Committee however has stressed that even in times of economic difficulty the state governments have obligations to prisoners:

“The CPT is aware that in periods of economic difficulties […] sacrifices have to be made, including in penitentiary establishments. However, regardless of the difficulties faced at any given time, the act of depriving a person of his liberty always entails a duty of care that calls for effective methods of prevention, screening, and treatment. Compliance with this duty by public authorities is all the more important when it s a question of care required to treat life-threatening diseases.”

This Thematic Report does not cover all health issues connected to women in prison but focuses especially on:

• Pregnant women and women accompanied by their children. • Matters of social rehabilitation and training.

The following section in this chapter will present some general regulations and recommendations regarding the major topics addressed in this Thematic Report. Regardless gender issues, it should be kept in mind that a number of principles should be kept in place, which women can rely on when requesting health and social care in prison.

One such principle includes Principle 1 of the United Nations Principles of Medical Ethics relevant to the Role of Health Personnel, particularly Physicians, in the Protection of Prisoners and Detainees against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment: “Health personnel, particularly physicians, charged with the medical care of prisoners and detainees have a duty to provide them with protection of their physical and mental health and treatment of disease of the same quality and standard as it is afforded to those who are not imprisoned or detained.”

2.2 Regulations on women’s health in prisons

This Thematic Report is based on major national and international instruments and guidelines, which regulate the conditions for women and infants in prison. The report therefore mentions legislation, regulations and recommendations, which particularly address the health of these vulnerable groups in prison:

• The European Convention on Human Rights; • The United Nations Convention on the Rights of the Child; • The United Nations Convention on the Elimination of All forms of Discrimination Against Women; • The United Nations Body of Principles for the Protection of All Persons Under Any Form of Detention or Imprisonment; • The International Covenant on Civil and Political Rights; • The Standard Minimum Rules for the Treatment of Prisoners; • The European Prison Rules, revised version (2006); • Recommendation 1469 (2000) on Mothers and Babies in Prison, adopted by the Council of Europe’s Parliamentary Assembly; • The Council of Europe’s Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment – The CPT standards.

Even if the conventions and treaties – for instance the UN Conventions and the European Prison rules – are not legally binding in the signatory states, they have to be treated as important recommendations. However, the Standard Minimum rules and the European Prison rules codify the legal and appropriate implementation measures in national prison regimes, in addition to national rules and regulations. They are especially important to countries in which these regulations are not yet in place, or are pending implementation. The international study on imprisonment of women by Frider Duenckel therefore questions the use of these international standards in the face of heterogeneous prison regimes and legal systems in different countries. On the other hand, his study points out that in spite of socio-cultural and socio-economic disparities, the general conditions and challenges faced by female prisoners are similar: “They are merely a small minority of the total prisoner population that the prison system is not geared up for. Against this background internationally accepted minimum standards are important – even when they are not legally binding by international law, they can develop moral authority, and can be used in international collaboration as a common basis for legal reforms and for further training programmes, etc” (Duenckel, 2005:9).

The following documents outline rules, regulations and recommendations for pregnant and child-bearing women, as well as for women in detention who are accompanied by their children:

a. The Convention on the Rights of the Child (1989) is a universally agreed set of non- negotiable standards and obligations. The Convention sets out the children’s rights in 54 articles and two Optional Protocols. The Convention is child-centric and deals with the children’s specific needs and rights.

• Article 2.2: “States Parties shall take all appropriate measures to ensure that the child is protected against all forms of discrimination or punishment on the basis of the status…of the child’s parents…”

• Article 3.1: “In all actions concerning children, whether undertaken by public or private social welfare institutions, court of law, administrative authorities or legislative bodies, the best interest of the child shall be a primary consideration.”

• Article 9.1 and 4: “States Parties shall ensure that a child shall not be separated from his or her parents against their will, except when competent authorities subject to judicial review determine, in accordance with applicable law and procedures, that such separation is necessary for the best interests of the child…Where such separation results from any action initiated by a State Party, such as the detention, imprisonment…of one or both parents or of the child, stat State Party shall, upon request, provide the parents, the child or, if appropriate, another member of the family with the essential information concerning the whereabouts of the absent member(s) of the family unless the provision of the information would be detrimental to the well-being of the child…”

• Article 16: “No child shall be subjected to arbitrary or unlawful interference with his or her privacy, family, home or correspondence…”

• Article 18.1: “States Parties shall use their best efforts to ensure recognition of the principle that both parents have common responsibilities for the upbringing and development of the child. Parents or, as the case may be, legal guardians, have the primary responsibility for the upbringing and development of the child The best interest of the child will be their basic concern.”

17 b. The United Nations Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment.

• Principle 19: “A detained or imprisoned person shall have the right to be visited by and to correspond with, in particular, members of his family and shall be given adequate opportunity to communicate with the outside world, subject to reasonable conditions and restrictions as specified by law or lawful regulations.”

c. The European Convention on Human Rights

• Article 8, Right to respect for private and family life: “Everyone has the right to respect for his private and family life, his home and his correspondence.

The convention recommends that “there shall be no interference by a public authority with the exercise of this right except such as is in accordance with the law and is necessary in a democratic society in the interest of national security, public safety or the economic well-being of the country, for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others.”

d. The Standard Minimum Rules for the Treatment of Prisoners

• Article 23.1 and 2: “In women’s institutions there shall be special accommodation for all necessary pre-natal and post-natal care and treatment. Arrangements shall be made wherever practicable for children to be born in a hospital outside the institution. If a child is born in prison, this fact shall not be mentioned in the birth certificate.”

The Standard minimum rules further recommend that: “where nursing infants are allowed to remain in the institution with their mothers, provision shall be made for a nursery staffed by qualified persons, where the infants shall be placed when they are not in the care of their mothers.”

The European Prison Rules from 1987 were recently revised (2006). Of special relevance to this Thematic Report are a new section on women and a section on infants.

a. Rule 34: “In addition to the specific provisions in these rules dealing with women prisoners, the authorities shall pay particular attention to the requirement of women such as their physical, vocational, social and psychological needs when making decisions that affect any aspect of their detention.

b. Particular efforts shall be made to give access to special services for women prisoners who have needs as referred to in Rule 25.4 (Particular attention shall be paid to the needs of prisoners who have experienced physical, mental or sexual abuse).

c. Prisoners shall be allowed to give birth outside prison, but where a child is born in prison the authorities shall provide all necessary support and facilities.”

d. Rule 36: “Infants may stay in prison with a parent only when it is in the best interest of the infants concerned. They shall not be treated as prisoners.

e. Where such infants are allowed to stay in prison with a parent special provision shall be made for a nursery, staffed by qualified persons, where the infants shall be placed when the parent is involved in activities where the infant cannot be present.

f. Special accommodation shall be set aside to protect the welfare of such infants.” e. The Parliamentary Assembly made in 2000 the following comments and recommendations about Mothers and Babies in Prison:

“Experts agree that early maternal separation causes long-term difficulties, including impairment of attachments to others, emotional maladjustment and personality disorders. It is also recognised that the development of young babies is retarded by restricted access to varied stimuli in closed prisons.

In view of the adverse effects of imprisonment of mothers on babies the Assembly recommends that the Committee of Ministers invite member states:

i. to develop and use community-based penalties for mothers of young children and to avoid the use of prison custody; ii. to develop education programmes for criminal justice professionals on the issue of mothers and young children, using the United Nations Convention on the Rights of the Child and the European Convention on Human Rights; iii. to recognise that custody for pregnant women and mothers of young children should only ever be used as a last resort for those women convicted of the most serious offences and who represent a danger to the community; iv. to develop small scale secure and semi-secure units with social services support for the small number of mothers who do require such custody, where children can be cared for in a child-friendly environment and where the best interests of the child will be paramount, whilst guaranteeing public security; v. to ensure that fathers have more flexible visiting rights so that the child may spend a little time with its parents; vi. to ensure that staff have appropriate training in child care; vii. to develop appropriate guidelines for courts whereby they would only consider custodial sentences for pregnant women and nursing mothers when the offence was serious and violent and the woman represented a continuing danger; viii. to report back on the progress made by the year 2005.” f. The CPT states in its 10th General Report (2000) about Women deprived of their liberty:

“It is axiomatic that babies should not be born in prison, and the usual practice in Council of Europe member States seems to be, at an appropriate moment, to transfer pregnant women prisoners to outside hospitals.

Many women in prison are primary carers for children or others, whose welfare may be adversely affected by their imprisonment (cf. also Recommendation 1469 (2000) of the Parliamentary Assembly of the Council of Europe on the subject of mothers and babies in prison).

In the view of the CPT, the governing principle in all cases must be the welfare of the child. This implies in particular that any ante and post-natal care provided in custody should be equivalent to that available in the outside community. Where babies and young children are held in custodial settings, their treatment should be supervised by specialists in the areas of social work and child development.

19 The goal should be to produce a child-centred environment, free from the visible trappings of incarceration, such as uniforms and jangling keys.”

The second major set of issues addressed in this Thematic Report concerns work, social rehabilitation and pre-release training in prisons, especially for female prisoners. National and international documents and guidelines set rules in place and offer recommendations that are meant to impact the standards enjoyed by men as well as women. However, insofar as such rules and regulations pertain to women, they are often ignored by prison authorities and not properly implemented within prison regimes.

2.3 Regulations on work and education in prisons

Several principal treaties, guidelines and recommendations point to the fact that prison authorities shall provide all prisoners with work and education. The following documents are of special relevance to this issue:

• The European Prison Rules – revised version 2006; • Recommendation Rec(2006)2 of the Committee of Ministers to member states on the European Prison Rules concerning work and education in prisons; • Recommendation by the Quaker Council of European Affairs. The European Prison Rules. A Gender Critique (2006); • The Standard Minimum Rules for the Treatment of Prisoners; • The Council of Europe’s Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment – The CPT standards; • A Human Rights Approach to Prison Management – Handbook for prison staff. Andrew Coyle, International Centre for Prison Studies 2002. a. The European Prison Rules – revised version 2006.

Several articles in this document particularly deal with work and education. The following articles are of special importance: • “Prison work shall be approached as a positive element of the prison regime • Prison authorities shall strive to provide sufficient work of a useful nature […] • As far as possible, the work provided shall be such as will maintain or increase prisoners’ ability to earn a living after release […] • […] there shall be no discrimination on the basis of gender in the type of work provided.” 10 • “The organisation and methods of work in the institutions shall resemble as closely as possible those of similar work in the community in order to prepare prisoners for the conditions of normal occupational life. • In all instances there shall be equitable remuneration of the work of prisoners. • As far as possible, prisoners who work shall be included in national social security systems.”11

10 The Quaker Council of European Affairs wants the addition of: “Whilst taking into account the physical differences of men and women. All employment shall accord with equal opportunities, laws and policies. Care shall be taken that female prisoners in a mixed prison do not take on a disproportionate share of domestic work within the prison.” 11 The Quakers also want to add: “Maternity leave shall be granted prisoners according to the practices/ laws of the general population. Prisoners caring for children should be allowed the free option of continuing with work or of caring for their children.”

The European Prison rules pay special attention to education in some of its articles, such as by stating that:

• “Every prison shall seek to provide all prisoners with access to educational programmes which are as comprehensive as possible and which meet their individual needs while taking into account their aspirations.

• Priority shall be given to prisoners with literacy and numeric needs and those who lack basic or vocational education.

• Education shall have no less a status than work within the prison regime and prisoners shall not be disadvantaged financially or otherwise by taking part in education.”

The rules also point to the necessity of libraries in the prison wherever possible, which can be organised in co-operation with community library services. Furthermore, the rules state that as far as practicable, education shall:

• “Be integrated with the educational and vocational training system of the country so that after their release they may continue their education and vocational training without difficulty”12 b. Recommendation Rec(2006)2 of the Committee of Ministers to member states on the European Prison Rules concerning work and education in prisons

Of particular importance in this case is the rule stating that:

“There shall be no discrimination on the basis of gender in the type of work provided.”

Further, the rule mentions that prison work shall be approached as a positive element within the prison regime, that authorities shall provide sufficient work of a useful nature, and that the work shall be intended to maintain or increase prisoners’ abilities to earn a living after their release. Moreover, the organisation and type of work shall “[…] resemble as closely as possible those of similar work in the community in order to prepare prisoners for the conditions of normal occupational life.”

“In all instances there shall be equitable remuneration of the work of prisoners.

Education shall have no less a status than work within the prison regime and prisoners shall not be disadvantaged financially or otherwise by taking part in education.” c. Recommendations by the Quaker Council of European Affairs follow the same line, namely that:

“Member states ensure that women are given equal access to education, training and work opportunities as male prisoners.

Member states ensure that women are given jobs and training which will provide them with skills that they can use on release. Jobs and training should not be allocated to prisoners on the basis of gender.”

12 The Quakers would like to add that: “Prisoners caring for children should be allowed the free option of continuing in education or of caring for their children full time.”

21 d. The Standard Minimum Rules for the Treatment of Prisoners

Several rules deal with work in the prison context. Some of the subparagraphs are quoted as follows:

Rule 71. (3): “Sufficient work of a useful nature shall be provided to keep prisoners actively employed for a normal working day.”

Rule 72. (1): “The organization and methods of work in the institutions shall resemble as closely as possible those of similar work outside institutions, so as to prepare prisoners for the conditions of normal occupational life.”

Rule 72. (4): “So far as possible the work provided shall be such as will maintain or increase the prisoners’ ability to earn an honest living after release.”

Rule 76. (1): “There shall be a system of equitable remuneration of the work of prisoners.”

Rule 77 is dealing with education and recreation:

“Provision shall be made for the further education of all prisoners capable of profiting thereby, including religious instruction in the countries where this is possible. The education of illiterates and young prisoners shall be compulsory and special attention shall be paid to it by the administration. So far as practicable, the education of prisoners shall be integrated with the educational system of the country so that after their release they may continue their education without difficulty.”

The CPT states in its 2nd General report (1992):

“A satisfactory programme of activities (work, education, sport, etc.) is of crucial importance for the well-being of prisoners.”

Chapter 3

WOMEN’S HEALTH IN PRISON IN THE NORTHERN DIMENSION AREA

3.1 The prison health situation in the ND area

Well-functioning medical services are of utmost importance for male and female detainees with shorter or longer prison sentences time, and even life-time sentences, in order to ensure the prevention and treatment of many health problems, as well as to offer programmes for rehabilitation and their reintegration into society.

The majority of penitentiaries do have some semblance of a health care system in place. The quantity and quality of the services however vary considerably, and a number of problems remain unsolved. Experience shows that people from the poorest and most marginalized sections of society make up the bulk of prison detainees. This means that the prison population mainly consists of persons with poor somatic health, persons infected with various transmissible diseases, chronic untreated conditions, vulnerable persons with psychological/psychiatric problems, and those who engage in at-risk behaviours such as intravenous drugs use and prostitution. The most considerable challenges for medical services are to treat and prevent the spread of communicable diseases such as HIV/AIDS and other sexually transmissible diseases, Hepatitis and Tuberculosis as well as to care for prisoners with mental disorders and drug addicts.

Over nine million people detained in penal institutions around the world. However, the figures for prison populations vary considerably between different regions of the world, and between different parts of the same continent. In Europe, close to 2 million prisoners are detained in various penal establishments (pre-trial institutions, correctional facilities, colonies, prisons, juvenile detention centres etc.) The highest number are to be found in the Russian Federation,

23 which in July 2007 had 889,598 detainees, of which 7,1 % were women and 2,5 % children and minors. The median rate of prisoners per 100 000 of the national population for European countries is 184. A study for the Northern Dimension Partnership in Public Health and Social well-being Progress report 2007 reveals that the rate per 100 000 of the national population varies from 628 in the Russian Federation, to 237 in Poland, 85 in France, and between 66-82 in the Scandinavian countries. Surprisingly high is the number of prisoners per 100 000 of the national population in Estonia (268), Latvia (292) and Lithuania (235) (NDPHS 2007: Annex 3).

A considerable number of penal institutions are located within the ND area. The institutions differ enormously in terms of living conditions, medical services and social programmes. Many challenges are cross-cutting, ranging from general somatic diseases, communicable and sexually transmitted diseases to severe mental health disorders. The NDPHS Expert Group on Prison Health focuses on prison health challenges related to HIV/AIDS, Tuberculosis and Hepatitis (B/C), drug addiction, alcohol and tobacco abuse and their consequences for somatic and mental health. The Expert Group pays particular attention to social rehabilitation as well as to vocational and educational training programmes. It is aiming to establish common and widely accepted recommendations and solutions for disease prevention, the improvement of health care and social work in prisons, drug and alcohol rehabilitation, social inclusion programmes and the improvement of mental health.

On their website, the non-governmental organisation Penal Reform International (PRI) informs about the situation of women in prison globally. It states that around half a million women and girls are imprisoned in different types of institutions worldwide. Countries with the largest population of detained women are the United States (183,000), China (71,280), the Russian federation (55,400) and Thailand (28,450).13 Compared to statistics on male detainees, women constitute a rather small group in prison, however also a growing one.

Women are usually imprisoned for minor offences, non-violent crimes, drug violations and criminal activity related to the purchase of narcotics, such as prostitution and burglary. Many of these women have ethnic, linguistic or indigenous minority backgrounds. In large part, they have dysfunctional social backgrounds and are also responsible for taking care of children and/or other family members. “Women, especially mothers, in prison have special physical, vocational, social and psychological needs. Yet, they often face problems with maintaining contact with family and the outside world, as well as difficulty in assessing education, training, work programmes, and health care while in prison. They are also vulnerable to abuse and violence including rape, inappropriate surveillance and strip searches. Women in prison have higher levels of depression, anxiety, phobias, neuroses, and self-mutilation, and suicide compared to the general population and male prisoners.”14

A major challenge to this study has been to find useful data on women in prison and their special needs. Exact data on prisons and imprisonment in general is difficult to find and it is even more difficult as concerns female prisoners. Many countries simply do not disaggregate data and cannot provide statistical information for male and female prisoners separately (which is a major problem because the general situation for female prisoners is different from their male counterparts as described above). The collection of data and statistical information on female prisoners is needed in order to advise and develop appropriate measures to meet their special needs. When countries do provide statistical information on female prisoners, their approaches to data collection differ widely across Europe. Many countries have no comparable definitions as to what constitutes a female inmate and what a women’s prison actually is. Sometimes there is statistical data available for pre-trial institutions for women, but not for closed institutions or vice-versa. Also, the methodology for collecting information and analysing statistical data on female prisoners differs between the countries. Some collect data on prisoners in general and

13 International centre for prison studies, 2006 world female imprisonment list. 14 http://www.penalreform.org/women-in-prison.html

24 estimate the number of female prisoners using different timeframes (e.g., average number for one specific day, estimated total number of female prisoners over a whole year, and percentage of the total prison population). International comparison of prison population rates cannot be viewed as being unproblematic either and should also be kept in mind. The categories included in the number of prisoners vary from country to country. Therefore, it is not possible to compare national data without reservations, as it is not necessarily apparent that different countries present information based on the same categories.

In order to compare data between countries and thereby make it possible to also compare penal systems for female prisoners across Europe, it will be important to develop general measures on how to collect statistical data. As already mentioned, exact figures on women as well as on other vulnerable/minority groups in prison are extremely hard to come by. In depth work and research in the social sciences field on these particular issues is very limited and remains far too general. The NDPHS PH EG appreciates the latest publication of the WHO Europe Office, Health in prisons – A WHO guide to the essentials in prison health. It provides as much information as possible (and as much as is available) on the conditions of women in prison. The Expert Group strongly recommends that further project-based activities that collect better and complete statistical data on women and other minority groups in prison be undertaken. Thereby, health indicators for imprisoned women have to be developed in order to be able to compare the health situation of female prisoners across the region and to develop general guidelines for a Gender Sensitive Prison Management and a comprehensive gender equal approach to prisons.

The point has often been made that it is very costly for states to organise separate detainment facilities for women and to provide them with specialised and focused health care. The result is that women are often held in institutions that are well-suited to their special needs, as such institutions are mainly designed for men in terms of their living conditions, education and training, leisure activities and health services. Gender inequality therefore runs rampant in terms of overall trends in imprisonment and particularly in the area of prison health: “In these circumstances, particular care is required to ensure that women deprived from their liberty are held in a safe and decent custodial environment” (www.cpt.coe.int/en/annual/rep-10.htm). The CPT has recommended a number of measures in order to minimize the risk to the physical and/or psychological integrity of women deprived of their liberty.

Some of these important measures are:

• Mixed gender staffing in prisons and especially in the health care sector; • Separate accommodation for women if they are imprisoned with men in the same building; • Equality of access to activities, as well leisure time as educational. Hereby the particular critic of the CPT on activities for women in prison should be highlighted: “all too often encounter women inmates being offered activities which have been deemed “appropriate” for them, such as sewing or handicrafts, whilst male prisoners are offered training of a far more vocational nature.” (www.cpt.coe.int/en/annual/rep-10.htm). This issue will be further discussed in chapter 5: Social rehabilitation and pre-release training. The PH EG believes that rehabilitation and pre-release training is an essential part of inmates’ social-well being and significantly contributes to a more successful reintegration into society after their release from prison (and is thus a major stepping stone to successful social rehabilitation).

According to the CPT, particular women’s hygiene needs should be addressed in an adequate manner. Access to sanitary and washing facilities as well as hygienic equipment should be available upon request. Furthermore, the CPT points to the need for ante natal and post natal care for pregnant women and those with newborn babies. Health care in prisons should be provided in accordance with the health care available to society at large. Prisoners (both female and male) should not be at a disadvantage in the case of access to adequate medical services.

This Thematic Report is based on statistical data and information from the Quaker Council for European Affairs, PRI, IPS and the CPT, as well as a questionnaire developed by the NDPHS Expert Group on Prison Health (attached as an Appendix to this study). The questionnaire was circulated to all members of the Expert Group during early November 2007 for the purpose of collecting the latest statistical information on women in prison in the northern Dimension Area. Information was also compiled on transmissible diseases, Tuberculosis, access to substitution and psychological treatment, and on the number of pregnant women and mothers in prison. The questionnaire was also designed to generate an overview of how the number of female prisons the ND area, where they are located, and how the health systems within these institutions are organized.

3.2 Female prisoners in the ND area

Female prisoners represent between two and ten percent of the total prison population in the world. During the last ten years, the number and percentage of female prisoners has remained relatively stable in the ND area within countries like Denmark, Latvia, Norway and Sweden. The number of female prisoners has increased in Estonia and Finland. In some other countries overall trends in the numbers and percentages of female prisoners are more complex, such as in Germany and Poland, where the numbers of female prisoners have increased while the percentage of the total prison population has remained consistent.15

On average, five percent of the total prison population in the Nordic countries consists of women. In general, “Women have been particularly effected by increasingly though anti-drug laws in some countries which have led to a much faster rate of imprisoned women” (European society of criminology 2007:13).

15 There has been an increase of the total number of persons who have been imprisoned in the Nordic countries (Denmark, Finland, Iceland, Norway and Sweden) over the period of 2001 to 2005 with 19%. For Finland, the increase has been 24%, for Denmark and Sweden 23%, and for Norway 15%. Iceland has had a stable prison population after 2003. (Nordisk statistikk for kriminalomsorgen i Danmark, Finland, Island, Norge og Sverige 2001- 2005, Rapport 1/2007 fra Kriminalomsorgen). The number of persons on remand in the Nordic countries has been relatively consistent.

26 Latvia 418 (2007) Lithuania 341 (2007) Es tonia 209 Sw eden 293 (Oct.2006) 4.061 Germany Poland 2.720

Iceland 6 Finland 245

2.144 France

170 Denmark

211 Norw ay Rus sia 60.668 (2008)

Table 1: Female population in prison – total numbers/ percentage of total prison population by 1 September 2006, if not indicated differently, also including pre-trial detainees.

1 Latvia 5 Lithuania

3 Es tonia

Sw eden 5 Germany 7 22 Poland

1 Ic eland

8 Finland

France 55

4 Denmark

Norw ay 9 45 Russ ia

Map 1: Number of women’s prisons and prisons with women units in countries in the ND region

3.2.1 Age

The PH EG has no information on the age groups of female prisoners in the ND area. Statistics from other European countries have been presented in a survey published in 2005. It indicates the age of female prisoners, as some of the countries to a certain degree are comparable. In most countries female prisoners are fairly young. “Those under 18 years old vary from less than 1% in France to less than 3% in England and Wales. Statistics from Hungary indicate that women under 19 years old represent 2% of all inmates; in Germany juveniles less than 18 years old represented 2% of women inmates. Of the data reported in all countries, more than one- quarter of adult women inmates are under 30 years of age. The figures for women ages 18 (19) to 29 years are very important in England and Wales (50%), and to a lesser extent, in France (42%). This age group is less important in Germany (32%), Hungary (31%) and Italy (29%). In these 3 countries, there are more women who are between 30 and 39 years old. Also, in these 3 countries, the percentage of women over 40 years of age is more important (33% in Germany, 35% in Italy and 37% in Hungary) than in England and Wales (18%) or even in France (29%). Nevertheless in all countries, more than 60% of adult women inmates are under 40 years of age and are therefore fairly young."16

3.2.2 Organisation of medical service within penitentiaries in the ND area

The legal responsibility for the provision of medical services in prisons differs from country to country. Prison administrations often face a dilemma in terms of balancing security requirements and public health requirements (for example to prevent the spread of blood-borne viruses or other infectious diseases in the society as well as within prisons). It has therefore been recommended the links between prison and public services be tightened, resulting a greater responsibility for the ministries of public health in several countries to provide health services.

In the Northern Dimension area the responsibility for the provision of health services in prison falls under different authorities. In those countries where the provision of prison medical services is placed under the authority of the Minister of Justice, a greater participation of the Ministry of Health would help to ensure optimum health care for prisoners as well as implement the general principle equivalent health care in prison to the outside community.

The organisation of medical services within female prisons varies from prison to prison, especially when it comes to the health care for special vulnerable groups such as women, juveniles and the elderly. Several important recommendations have been made by the CPT “Health care services in prison” which are published as an extract from the 3rd General Report (CPT/Inf (93)12). These recommendations are applicable to both male and female prisons.

16 European Commission, DG Research EC, 2005: Women, Integration and Prison. An analysis of the processes of socio-labour integration of women prisoners in Europe - MIP PROJECT. http://cordis.europa.eu/documents/documentlibrary/2746EN.pdf

3.2.3 In practice within the ND area: General Health

Prisons for women in Latvia and Estonia have their own medical departments and mother and child units. They have also their own prison hospitals, which are located close to a public hospital, operating in cooperation with the prison.

Sweden/Latvia: Cooperation between women’s prisons in Sweden and the Baltic countries (SIDA evaluation, 03/11/). The Ilguciema Colony for Women and the KVM Hinseberg Prison for Women in Sweden are two female establishments participating in twinning programmes.17 The report emphasises significant changes in the attitudes and behaviours of staff members towards one another, and between staff members and prisoners. The positive use material support given by the Swedes, e.g., school equipment and furniture, computers, laundry equipment, kitchen equipment and workshop equipment etc, was observed. In terms of direct results, the 12-step programme for alcohol and drug addicts was highlighted as one of the most beneficial outcomes of the twinning. Staff members were trained by Swedes and the Prison Fellowship International (http://www.pfi.org/) helped to restore a venue in which the course could take place. There have also been direct developments in education, vocational courses, and in particular, computers (which were also provided for the staff).

Norway/Russia: The Twin Prison Project started at the end of the 1990s as a humanitarian measure. Lorries with clothes, hygienic tools and other related items were sent to Russia. At the same time, the female prison Bredtveit started co-operation with a twin prison in the Mozhaisk female colony. The colony houses from 1,000 to 1,200 inmates in addition to approximately 100 children who are between the ages of 1 month to 3 years old.

Gradually it developed into a project for providing money to improve the living conditions, and especially the bathrooms, in the prisons. A delivery-room was renovated and the Bredtveit prison partly financed a mother-and-child unit where women detainees can stay with their children. The mother-and-child unit was completed in 2007. Financial contributions have also been made to the prison hospital and the prison church.

The Twin Prison Project had a dual focus. On the one hand, it focused on provided financial support for renovations, on the other hand, to develop professional co-operation in regards to the implementation of the VINN-program (see Chapter 5). Money has not been transferred after 2006. Another female prison in Norway, Ravneberget prison, and Bredtveit prison are working close together to implement the project in Russia.

Another professional project between the two female prisons in Norway and the Mordovia region of Russia with 3,000 female prisoners has taken place. The co-operation is only professional, focusing on training for program facilitators.

All prisons are concerned about the children who live on their premises. They can stay together with their mothers for up to three years. The women show interest in learning about the role as

17 Twinning - Twinning is considered to offer enhanced possibilities for organisational learning and sustainable capacity building, in contrast to traditional technical assistance, e.g. the use of short- or long-term experts. However the institutions describe the twinning in other terms. They regard twinning as the process of building mutual trust and understanding of a long-term character. They generally claim twinning has been most helpful, and we agree that it has worked well. We also find the decision to concentrate initially on building up professional understanding, mutual trust, and friendship as justified. Investments must be made in creating the relationships upon which activities can be further built and changes viably implemented. It has often been the case that trust and personal relationships have contributed to practical policy changes within prisons. Frequent topics addressed by such cooperation are staff- inmate relations; dealing with violent prisoners; staff “debriefing”; health (TB and HIV/AIDS) and hygiene; drug awareness and rehabilitation; work and vocational training; security and control; psychology and social work; preparation for release; probation service; teaching methods and programmes; and others related area of focus.

29 parents. Overall, the number of inmates in Russian prisons has increased. Alternatives to imprisonment have been discussed, and the prison authorities in the Mordovia region have displayed and interest in learning about the Norwegian approach to alternatives. A seminar focusing on alternative measures is planned to take place during 2008.

3.3 Main health problems encountered by women in ND area prisons

There is no question that male and female prisoners shall have access to the same medical services. The standard of health care shall be at least equal to the best health care provided in general or available to the average members of the larger community. Women seem, however, to have greater needs for health care, both in the community and in prison. A survey from the National Institute of Corrections in Washington, DC has shown that 20-35% of women enter prison while already sick compared to 7-10% of men. Even if figures from prisons in the ND region cannot be documented, there is little doubt that female prisoners need more medical attention than men.

Women’s health problems can roughly be divided into four main categories: somatic diseases, including transmissible diseases (TB, HIV/AIDS, hepatitis etc.) and dependency-related diseases; mental health problems/disorders such as depression, anxiety, stress, psychosis, personality disorders, self-harm, suicide attempts/suicide, drug-induced disorders, ADHD and PTSD; women-specific health-related problems/diseases; other problems, for instance the consequences of having been victims of exploitation, physical/emotional abuse, human trafficking. This Thematic Report will focus especially on HIV/AIDS, Tuberculosis and what we refer to as Women-specific health-related problems/diseases.

“Delays in health care treatment, such as scans during pregnancy and screening for cervical cancer and breast cancer, may adversely affect women in prison and choices they can make surrounding their health. A break in receiving the contraceptive pill heightens women’s risk of unintended pregnancy. Women should be able to see a female nurse and doctor on request; failure to do so may result in certain medical problems not being reported. As prisons often have only one prison doctor this may be more difficult to provide than in a normal clinic/doctor’s’ surgery.

The small number of women prisoners may mean prisons are more likely to employ male medical staff. Women need adequate toiletries, such as a choice of feminine hygiene products, soap that is suitable for sensitive skin and enough shampoo to wash long hair. In many prisons, hygiene provisions for women are inadequate and access to showers may be severely limited. Women need different health as men e.g. information on sexual and reproductive health, breast cancer, osteoporosis and hormonal problems. Women going through the menopause need information in order to make choices about how to manage this period of their lives and may need dietary supplements. (In Denmark, nutritional supplements may not be brought into prison, thus women will need prescription supplements). Appropriate health information is particularly important for psycho-social illnesses such as eating disorders, self-harm and some mental health problems” (Quaker Council of European Affairs 2007: 46ff).

3.3.1 HIV/AIDS

The best overview of the HIV-situation is provided by a report from the Penal Reform International, Briefing nr 2: In most countries, the prevalence of HIV infection in prisons is significantly higher than within the population outside prison. In Poland, 20 per cent of the country’s 7,000 infected people have spent time in prison or pre-trial detention facilities during their lives. Similarly, in Latvia, one-fifth of the HIV cases concern people in prison (UNDP, 2004). Current indicators suggest that HIV prevalence is increasing at a dramatic rate. The

30 former Soviet states have experienced a particularly rapid increase in HIV prevalence in prisons. In Russia, the number of prisoners living with HIV increased from seven in 1994 to 36,850 in 2002 – an increase in the prevalence rate from 0.008 per 1,000 inmates to 41.1 per 1,000 inmates (UNDP, 2004). Similarly, in Ukraine, admissions of prisoners with HIV increased from 11 in 1994 to 2,939 in 1997 (WHO Europe, 2001). In Lithuania, an HIV outbreak in Alythus prison in 2002 resulted in 263 prisoners testing positive for HIV within just a few months. Prior to this, there were only 18 known HIV infections within the entire prison system and 300 people living with HIV in the country as a whole (Jurgens, 2002). HIV prevalence is compounded by the high rates of hepatitis C (HCV) and tuberculosis (TB) infections in prisons.

Women are more at risk of contracting HIV from sexual activities than men are, due to a number of factors: The main groups at risk are young women engaging in at-risk sexual behaviour with multiple partners, engaging in intravenous drug-use, have a history of drug-related offences and are involved in prostitution. Women may enter prison pregnant but unaware of their pregnancy status due to their unconventional living conditions. Such women may even become pregnant while prison on the account of visitations by their partner(s). Vulval and vaginal inflammation can increase the likelihood of acquiring HIV infection. Thus, sexually transmitted diseases can increase the likelihood of eventual HIV infection, especially if the sexually transmitted infection (STI) is not detected and properly treated.

Many female prisoners have problematic social and criminal backgrounds. “Prisons could provide a forum for a last chance of reaching marginalized and often confused women […] will be most at risk of contracting HIV” (Reyes 2001). A prison can often be the only place where a sick woman has the time and the resources to receive treatment from doctors or gynaecologists, as well as a diagnosis, treatment and potential cure for whatever disease they have contracted. “STI monitoring may therefore offer a useful indicator of change in sexual behaviour” (Reyes 2001: 195). Gender inequality, the lack of education, unemployment, poverty, prostitution, physical abuse, and forced unprotected sex render women at higher risk to be infected by HIV. Many women have a long history drug addiction and intravenous drug use, which also places them at higher risk for hepatitis and HIV infection.

According to official figures, approximately 35,384 of Russian inmates are HIV positive, with this figure rapidly increasing. The number of HIV positive people entering the prison system is rising by an average of 15 to –20 percent each year. There exists a combination of risk factors such as tattooing with shared needles, sexual activity in prisons, and intravenous drug use (with shared needles). Approximately 96,915 inmates are reported to be drug addicted, with 61,579 being dependent on alcohol, and one-third suffering from various psychological and psychiatric disorders. About 100 convicts with AIDS are imprisoned (CPT 2003/ 89).

In Latvian prisons in 2006, “prisoners contributed to 16 percent of all new cases, which used to be 30-33 percent during 2000-2003 respectively. A decline in the share of new HIV positive cases found in penitentiary system can be attributed to the declining number of individuals who are tested by the prisons. If in 2000 the prison system tested 8,722 individuals, this number declined to 2,600 in 2006 (new entries per year approximately 3.000). Since 2000, due to lack of financial resources and outdated infrastructure, the number of HIV tests has been reduced. The incidence of HIV in prison is ten-fold higher than in within the greater community. Therefore, the situation within penitentiary system remains to be a problem and still poses a risk for the spread of HIV. Such a risk is due to the fact that approximately 6.1 percent of prison population (December 31, 2006) is HIV positive (UNGASS 2008a: 10).

In Estonian prisons “in 2000, 80 inmates who were HIV positive were detected and formed 20% of all new HIV cases. In the years that followed, the proportion of inmates who are HIV positive has increased. In 2003, 266 people were detained in a penal institution upon the moment of HIV detection, accounting for 32% of all new cases. In 2004 the inmates formed 21% (155 people)

31 of all new HIV positive cases. The majority (89%) of inmates infected with HIV are men between the ages of 15 and 24. Approximately 12-13% of all inmates in Estonian prisons were infected with the HIV as of 2004. Since 2004 the proportion of prisoners among new HIV cases decreased to 19% (118 people) in 2005. Most prisoners are infected before the actually enter the prison. There have been seven cases (according to the data from the Ministry of Justice) of HIV transmission in the prison (one trough tattooing, five through sharing contaminated syringes, and one unknown)” (Estonian Ministry of Social Affairs 2008:7).

As already mentioned, prisoners are at an exceptional risk of HIV infection because of the connection between intravenous drug use and imprisonment. HIV infection is currently a serious problem in juvenile prisons. It is feared that a second phase of the HIV epidemic will be characterised by heterosexual transmission, which would further aggravate the situation. Women prisoners who have engaged in prostitution are at an additional risk.

The two first HIV cases among IDUs in Estonia were diagnosed in 1997. From September 2000 onwards, the number of HIV positive persons increased rapidly. HIV infections are primarily seen among IDUs. The first HIV positive person detected in prison was diagnosed in May 2000. By October 2001, 464 HIV positive persons had been detected, among them 47 women and 65 minors, and all of them drug users. Newly arrived prisoners are examined at the Central prison hospital in Tallinn. Previously, testing was conducted mainly among risk groups such as IDUs, sex workers, homosexuals and patients with hepatitis B or C due to lack of resources. More funds have however now been available. Testing is voluntary.

In order to purchase drugs, many women earn money by way of prostitution or engage in at-risk sexual activities while under the influence of drugs. There is often uncertainty about their partners, and the protection offered by condoms is compromised by violent sexual intercourse or sexual abuse. These factors increase the risk of being infected with sexual transmitted diseases or bloodbound viruses such as HIV. “Health services in women’s prisons need to be resourced to take account of this particularly high demand” (WHO 2007:166). As the HIV virus is not only found in semen or blood but also in breast milk and vaginal fluid, prisons must be equipped to meet the needs of female prisoners, especially vulnerable or minority groups including pregnant prisoners or homosexual women (Curtis 2006). The correct use of condoms should be basic practice in relation to all types of sexual activity, whether vaginal, anal or oral, as it can greatly reduce the risk of acquiring or transmitting STIs such as HIV. The WHO Health in prison guide suggests the following components for comprehensive HIV treatments in prison18:

• Providing easy access to voluntary HIV counselling and testing; • Conducting surveillance of HIV and AIDS; • Mitigating social impact by undertaking measures to counter HIV-related stigma and discrimination; • Mitigating HIV-related diseases by providing appropriate care, treatment […] and support for HIV and related diseases; • Preventing new infections through: reducing sexual transmission by providing life skills […], providing easy and anonymous access to condoms and lubricants, controlling sexually transmitted infections, notifying partners and implementing measures aimed at reducing sexual abuse and rape; • Ensuring blood safety by testing transfused blood for HIV, reducing the number of non- vital blood transfusions and enrolling donors at lower risk;

18 Important guidelines are “HIV/AIDS Prevention, Care, Treatment and Support in Prison Settings” - A Framework for an Effective National Response prepared by UNODC and Co-published with the World Health Organization and the Joint United Nations Programme on HIV/AIDS (UNAIDS).

32 • Reducing the incidence of transmission through sharing contaminated injection equipment, needle and syringe programmes, substitution therapy and peer based education [including special education for minority groups as e.g. women having sex with women].

As documented by several researchers, heterosexual relations are becoming the leading risk factor for females within a certain age group for being infected with HIV. With the increasing transmission of HIV/AIDS and its specific manifestations in women, this also becomes an issue for the prison environment, which complicates the treatment and care of female prisoners, especially for pregnant women. On the other hand, being HIV positive and going through the prison system also provides a unique opportunity for receiving treatment, education and counselling on HIV/AIDS issues. In most countries and institutions in the ND region, women have the possibility to receive antiretroviral treatment.

HIV treatment in prison has mainly been focused on male inmates, as the female prison population is always comparably smaller. Consequently, women’s specific needs are often neglected. The prison environment does not always take into account the specific needs of women, such as accessibility to regular showers, the greater need for hygiene products due to menstruation, the need to make sanitary napkins available and to dispose of them properly, and adequate nutrition for pregnant women as well as women who are infected with diseases such as HIV/AIDS.

3.3.2 HIV positive pregnant women in prison

“The transmission of HIV from a pregnant mother to her unborn child is the most common source of HIV infection among children. The most effective interventions that can help to reduce this transmission depend upon a pregnant woman first knowing her HIV status. Therefore it is recommended that information, counselling during pregnancy as well as around the time of and after delivery, and any voluntary testing service should be available to women prisoners” (Reyes 2001). Furthermore, the possibility of terminating the pregnancy should be an option, taking into account the legislation of the country. “Pretest counselling should be provided by trained medical staff, such as midwives trained in HIV education” (Reyes 2001).

Another way that pregnant women transmit HIV to their children is through breastfeeding (as the virus can be present in breast milk). The report states that this predicament has not undergone sufficient research and the extent to which viral loads in the blood and maternal milk are correlated should be further researched. However, “all preventive measures for HIV should be available for pregnant women in prison who have family visits, and proper counselling provided about HIV infection. Whenever relevant, the use of condoms during pregnancy specifically to avoid possible HIV infection should be explained and encouraged. Condoms should be available to all prisoners without undergoing embarrassing situation as to having specifically asked for it. Further research has shown that the possibility of HIV transmission is significantly higher when the mother is infected during pregnancy or when breast-feeding, if she is in an advanced stage of the disease (AIDS) or has a high viral load (shortly after infection)” (Reyes 2001).

Furthermore, transmission of the HIV virus from the mother to her child occurs during childbirth, when the foetus passes through birth canal. In order to minimise the risk of infection, C-sections are often (and should be) preformed on HIV-infected women in childbirth (equivalence of care). C-sections should also be an option for every pregnant female prison detainee and performed by specially trained personnel. Postpartum care should be similar for women with and without HIV infections. Mothers should be provided with information and training as to on how they can safely handle bloodstained sanitary pads and material used after delivery.

33 “In Latvia for example, annually ~30 HIV positive pregnant women are detected. As of December 31, 2007 there were 25 HIV infected children born to HIV infected mother in Latvia. Out of all HIV cases, among pregnant women 49.3% are reported due to sexual transmission and in 25.9%, the women have a history of drug injecting7. HIV cases among pregnant women in Latvia are mostly found among mothers that avoided adequate prenatal care as well. This may suggest that pregnant IDUs are not adequately reached by HIV testing during pre-natal care services in Latvia” (UNGASS 2008a: 11).

It would be favourable to have more NGOs involved in prisons that face HIV-related challenges and reproductive health issues. It is no doubt that women should be the first group to receive interventions concerning measures to curb at-risk behaviours and treat their health-related consequences. Of course it is also important to involve men such prevention and treatment processes.19

In the guidelines HIV/AIDS Prevention, Care, Treatment and Support in Prison Settings” - A Framework for an Effective National Response prepared by UNODC and Co-published with the World Health Organization and the Joint United Nations Programme on HIV/AIDS (UNAIDS), the following recommendations for HIV treatment of women in prison are given:

1. Provide appropriate reproductive health and gynecological care services for all women. 2. Provide quality obstetrical care for HIV-positive pregnant women in prison, including antiretroviral therapy on a continuous basis, and prophylaxis for the infant during and post-delivery to ensure that vertical transmission of the infection is interrupted. For infants kept in detention with their mother, provide pediatric care for those infants found to be HIV-positive.

3.3.3 In practice within the ND area

All countries within the ND region have the experience of establishing special measures for prisoners who are infected with HIV. The following includes some examples which might be of interest to other penal establishments.

Estonia: WHO Health in Prisons Project - Best Practice Award 2007 Best Practice Award 2007 in Category 1 went to Tartu Prison in Estonia. The category includes any aspect of the clinical care provided to prisoners by doctors, nurses or other healthcare professionals.

HIV prevention and care in Tartu prison

The aim of this project was to improve the accessibility of voluntary counselling and testing (VCT) and antiretroviral treatment (ARV), increase distribution of information to prisoners and prison staff. The target groups were prisoners and prison staff members who were in close contact with prisoners as both guards and contact persons.

The rapid spread of HIV/AIDS has been the most serious health problem in Estonia since August 2000. The epidemic escalated very quickly. The main source of the epidemic was IDU (intravenous drug users). A considerable number of drug users are admitted to the prison.

19 “The global experience shows that prisoners as well as other groups at risk are best served when external agencies (governmental and NGOs) are involved in delivering HIV prevention and curative services. Therefore states’ agencies (PHA, LIC, SATLD, RCPAD) that receive funding from budget have to deliver HIV/AIDS, TB, hepatitis, STI testing, prevention services and care in prisons. Such involvement of respective agencies and NGOs should be aimed at developing and delivering confidential, competent and coordinated prevention, treatment and support to those in the places of detention” (UNGASS 2008:30).

34 Prison staff plays a prominent role in educating prisoners on how to minimise virus transmission, how to reduce at-risk behaviour and harm reduction. Increased knowledge of HIV/AIDS will reduce discrimination against those who are infected. The entire medical staffs of Tartu prison and specialists from the community hospitals have been involved in the program.

The aim of the project is to build up a system that provides constant VCT, ARV treatments and care, and reduces at-risk behaviour on the part of prisoners. In order to achieve the goals of the project, the following activities are carried out:

• Voluntary testing and/or re-testing if needed; • Pre-and post-test counselling; • Timely access to medical care; • Access to HIV specialists; • Regular HIV education for prisoners and members of the prison staff, including medical staff.

This project began in 2002 and is still active. Over 8000 inmates have participated in the Project between 2002 and 2006.

There is voluntary HIV testing for every incoming detainee to Tartu prison. According to the Quakers’ observations, medical staff tries to persuade as many prisoners as possible to undergo testing, and to receive counselling and advice. HIV positive prisoners are not kept separately from the other prisoners, and treatment and supervision is confidential. If a woman is HIV positive it is left up to her who she will share information with concerning her HIV status. Also, testing for STIs upon arrival is voluntary. The QECA reports that for many women it will be the first time they take part in a gynaecological examination for STI and or see a gynaecologist. This situation is mainly the result of women’s poor social, educational and economic backgrounds. Homosexuality among women is more or less ignored, while the prison does not provide female inmates with condoms (these are only provided to male inmates. However, the medical facilities for female treatments are considered to be of an excellent quality by the QCEA observer and by the CPT. Pregnant women do not have to leave the prison for pre-natal ultrasound scans and female prisoners have the option to be examined and treated by female medical staff (Quaker Council of European Affairs 2006, part II country report Estonia).

Estonia: NGO Convictus originated in Sweden and was started in Estonian prisons during the end of 2002. It has now 25 employees of whom 50% are ex-clients. They have received funding from different sources. Since September 2007, the Estonian Ministry of Justice finances the support group service in prisons. According to the terms of the contract between the Ministry of Justice and Convictus, they provide:

• Support groups for HIV positives within prisons in Estonia; • Counselling; • Education for prison personnel and prisoners.

Besides these, they also provide within the community:

• A support group for ex-prisoners; • A support group for women engaging in intravenous drug use and for those who are HIV positive; • Community-based needle exchange and counselling programmes.

Convictus representatives visit prisons throughout Estonia, including the Harku female prison, weekly. As far as possible, they meet with groups of six to eight prisoners. They provide advice on health care and harm reduction services for drug- and alcohol addicts, and offer links to

35 community services in order to provide through-care services. They also have a contract with the Family Planning Programme, which has been seeing around ten prisoners in each of their group meetings (with two groups per week over the last six to twelve months.) The groups are offered both in the Estonian and in the Russian languages. Prisoners learn about the Convictus groups from each other and must submit an application to join the group. Convictus also holds information days in order to reach out to more prisoners at any one time, which is also important for those serving shorter sentences and are eager to join the group meetings. Convictus staff also has a valuable role in training prison staff members and making them aware of the needs of prisoners who are addicted to drugs or who are HIV positive.

Convictus offers expertise and support to prisoners who may not feel that they are able to seek contacts elsewhere, due to concerns about being judged or not being treated humanely.

The government in Estonia now acknowledges them as an important part of the rehabilitation of prisoners, and they will therefore continue to receive state funding until 2015.

Russia: “In 1999 PRI implemented an 18-month HIV prevention project within the penal establishments of Nizhniy Novgorod. The aims of the project were to raise awareness about HIV infection and prevention among the prison population, improve the living conditions and treatment of HIV positive prisoners, and provide materials to aid the prevention of HIV transmission. Activities included the provision of training and relevant educational resources, organising study visits, researching prisoners’ attitudes and knowledge about HIV/AIDS and facilitating bleach distribution within the prisons. The project resulted in significant improvements in the living conditions and provision of activities for prisoners with HIV or tuberculosis. This included enabling them to have greater access to their families. The improved awareness of HIV/AIDS among both prison staff and prisoners served to abate fears and reduce the stigma attached to the virus. The project also led to the initiation of a peer learning programme within the prisons” (Penal Reform International 2007).20

3.4 Tuberculosis (TB)

TB is the main cause of death for people living with HIV/AIDS and as such presents a serious risk to those infected with the virus. TB infection rates in prison can be between five and ten times the national average (Farmer & Yang, 2004); in some cases, this can increase to as much as 100 times the prevalence rate found outside prison (Reyes, 2007). The prevalence of multi- drug resistant strains of TB (MDR-TB) and extreme drug resistant (XDR) strains are also higher in prisons than the rest of the population. “These trends culminate in high TB mortality rates in prison. In some prisons in Russia, TB accounts for up to 80 per cent of inmate deaths” (Farmer & Yang, 2004). The spread of Tuberculosis (and other transmissible diseases) is a big concern of several of the countries in the ND region. It has become an enormous problem for the prison authorities and for many penitentiaries. A news flash which was disseminated via the Council of Europe in 2003 emphasised that “Tuberculosis and AIDS rule in Russia’s overflowing prisons” and also described that more than 86,000 of almost 900,000 inmates – around one in 10 – were infected with the respiratory disease, and some 30% of ill inmates were infected with the resistant form of Tuberculosis.21

20 Further information: Reyes & Bollini (2000) Evaluation of the implementation of the project of HIV prevention and management activities in the prison system of Nizhniy Novgorod oblast, Russian Federation. Available in English and Russian 21 “In Russia, petty drug offences account for 75 per cent of female prisoners” (Wolfe, 2004). “Prison sentences are the norm for arrested drug users rather than diversion into drug treatment or rehabilitative programmes” (Walcher, 2005). “The consequences of punitive drug policies are high rates of imprisonment and a high concentration of injecting drug users in prison, which in turn drive the HIV epidemic and contribute to prison overcrowding” (Penal Reform International 2007).

36 In 2003 the Russian authorities reported however that the spread of TB in detention centres and prisons had halted. A drop of 27% of TB cases had been seen in 2002. According to the authorities there had been over 100,000 TB cases in penal institutions in 2001 whereas in 2003 the figure was at 77,000.22

WHO has reported that TB is up to 100 times more common in prisons than in the civilian population and its spread is exacerbated by late diagnoses, late treatment, poor prison conditions and overcrowding. HIV infection dramatically increases the risk of developing active Tuberculosis. The Baltic countries and the Russian Federation have the highest figures of MDR- TB in the world. New HIV cases in Eastern Europe consist of 75% IDUs, 77% men, and 84% are under 30 years old.

Even if the PH EG cannot point to exact numbers of TB-infected prisoners in the ND-countries, in 2007, there was sufficient documentation to show that TB in prisons still constitutes a very big problem to which it has to be paid much attention.

Tuberculosis affects the most vulnerable groups in society, including prisoners. Prisoners live mainly under poor conditions of health that result in the increasing problem of communicable diseases in prisons, especially as concerns Tuberculosis. Overcrowding, a lack of proper nutrition and poor hygienic conditions (especially a lack of proper infection control measures23) has led to an increase in the number of prisoners infected with Tuberculosis. Mainly the new member states of the European Union (EU) and Russia were affected by the spread of TB in the early 1990s when social and economic transformations in these countries resulted in larger vulnerable groups within the general population, including socially marginalised individuals who suffered from disease, malnutrition, weak immune systems and drug addictions (in which case many people were also infected with HIV/AIDS).

To combat the spread of TB from prisons into the society at large, the following is needed:

• Hygienic and general conditions in prisons must be improved; • Treatment against TB must continue after release; • All relevant actors and services including health care services, social services, the judicial system, media and NGOs must try to combat the spread of communicable diseases. They can also play an important role in the prevention of such infections within prisons society at large.

The CPT recommends that: “For control of the transmissible diseases to be effective, all the ministries and agencies working in this field in a given country must ensure that they coordinate their efforts in the best possible way. In this respect the CPT wishes to stress that the continuation of treatment after release from prison must be guaranteed.”

22 Treatment outcome reporting show that there are major problems of treating TB patients successfully even in case of drug sensitive TB, mainly due to treatment interruptions, especially after release from prison and due to lack of information in case of transfer from one prison unit to another. The equipment for detecting TB, especially the laboratory equipment, is also lacking or in poor quality in many penitentiary units. 23 Appropriate measures would be: Cohort patients in different rooms depending on their infectious status; proper control of airflow from non-infective airspace or rooms to infective airspace or rooms as TB is transmitted via infected air and use of personnel respiratory protection devices).

3.4.1 In practice within the ND area: TB/ HIV

Estonia: Activities to contain the spread of TB within prisons are an integrated part of the National Tuberculosis Programme (NTP) in Estonia. The reporting/recording system in the prisons has been part of the National TB Registry since 1999 when the DOTS strategy was introduced into the prison system. The main idea of the project is to establish a well-functioning data exchange system between the NTP Registry and the prison hospital.

One of the weak sides of this process is the collection of the screening-data when convicts enter the prison and throughout their stay. The follow-up activities vis-à-vis prisoners with TB who are released from the Prison hospital are another problematic process. This is connected to the problem of data exchange between the civil society and the prison system. According to data from the NTP Registry, many of the released prisoners do not continue their treatment after being released.

The adequate and timely information exchange between the prison system and the civil society as well as within the prison system will increase the possibility of improving the management of TB and the MDR-TB problem in Estonia. Strengthening data collection and data management will help to improve TB containment activities within the prison system as well as in civil society. This is of crucial importance because of the MDR-TB and the increasing problem of HIV/AIDS within general society and the prison system. According to data from the NTP Registry, the prison system contributes approximately five percent to annual national statistics. 24

Norway: The “Task Force on Communicable Disease Control in the Baltic Sea Region” has invested quite a lot of financial resources in various projects during the 1990s and over the first years of the new millennium to combat communicable diseases. In 2002 a small expert group visited prisons in Estonia and Lithuania in order to assess their situations concerning transmissible diseases. The assessment and results of the project included the issuance of recommendations to prison authorities in the two countries and as well as to the Task Force. These were published and can be found within the NDPHS project database.25

Finland/ Russia: The Finnish organisation FILHA has several projects in Russia. TB control in penitentiary care in Finland is integrated in the general public health care system. In connection with the updating of the Finnish TB control program, a new national program for TB was published in 2006 and extensive trainings for all health care units in penitentiary health are ongoing. Responsibilities of different actors and the flow of exchange of patient information have been clarified. Additionally, to improve monitoring of case findings and treatment measures to prevent transmission, construction of i.e. negative pressure isolation units have been undertaken in the central penitentiary hospitals.

As part of the National TB control program and as TB does not recognise borders, Finland has since 1996 had intensive TB cooperation with its neighbouring countries Russia and Baltic States. The Finnish NGO FILHA (Finnish Lung Health Association) implemented TB projects in Estonia and North-West Russia (Leningrad region, Murmansk region, Karelia and in St. Petersburg) funded by the Ministry of Foreign Affairs of Finland. Penitentiary care was included in Murmansk region partly with Norwegian funding. In Karelia and St. Petersburg the Finnish Ministry of Justice has with technical assistance from FILHA implemented TB projects. These projects are funded by the Ministry of Foreign Affairs of Finland. In framework of the No-TB

24 “There are 5 separate TB departments in Estonia with 230 beds including 30 beds for compulsory treatment. There is one separate department for prison system (40 beds)” (Ministry of Social Affairs 2008:22). 25 Based on information from the Norwegian Bredtveit prison there are no known cases of TB. All prisoners are screened at the entrance to prison.

38 Baltic program, FILHA cooperated with Estonia and additionally with the Latvian penitentiary care. More information can be found within the NDPHS project database.

In the Finnish TB project in penitentiary care in the St. Petersburg and Leningrad Region, the main focus of the activities is on three pilot sites. Since 2007 only the female TB patients were treated in the central penitentiary hospital TB ward. The staff from all units diagnosing and treating TB patients (meaning also the female isolator and colonies) are included in the training activities.

Russia: The Russian Red Cross (RRC) with the support of International Federation of Red Cross and Red Crescent Societies is realizing two programmes on TB: 1. "Comprehensive Model of Tuberculosis Control in 6 regions of Russian Federation". In its frames, RRC regional branches psychologists begin to work on TB treatment adherence with TB patients in colonies two months before release. This work is conducting for both men and women. After the release the patients are getting social/nutritional support as incentives to keep on adherence. 2. "HIV prevention in penitentiary system" in female prisons of three regions: Orel oblast, Chuvashia Republic and Khabarovsk kray. 26

26 There were not any activities on HIV+TB until today. In April, RRC is planning "HIV+TB" training for regional branches staff and prisons medical staff of these regions. So, the trained specialists will be conducting regular 1,5 hour HIV+TB prevention seminars for prisoners and prison staff after that.

39 Chapter 4

PREGNANT WOMEN AND MOTHERS IN PRISON

Photo by Juerg Christandl

Women who are pregnant or caring for small children constitute an extremely vulnerable group within the prison population. This has been well documented by the Quaker United Nations office in the publications “Women in Prison and Children of Imprisoned Mothers” (2004) and “Pre-Trial Detention of Women and their Children” (2006). “There is little public awareness of conditions in prison in which pregnant women and new mothers are held” (Kitzinger 1997).

The University of Greifswald conducted an international study on female prisoners which shows that out of the overall number of women interviewed, 70,2% in Poland, 68,7% in Lithuania, 67,8% in Germany, 63,5% in Russia and 57,7% in Denmark were mothers.27

“The imprisonment of a woman who is a mother can lead to the violation not only of her rights but also the rights of her child(ren). When a mother is imprisoned, her baby or child(ren) may stay with her in prison or be separated from her and left on the ‘outside’. Both situations can put the child at risk” (QCEA 2007: 5).

27 Cited by the Quaker report 2006.

4.1 Pregnant women in custody

In general, “Pregnant women and women with young children should not be imprisoned unless absolutely necessary” (UNODC 2007a: 50). Alternative, non-custodial measures should be taken into account. In cases where it is absolutely necessary to send a pregnant woman or a woman who has just recently given birth to prison, authorities should consider alternatives to pre-trial detention for mothers of babies and dependent children. This includes measures clarifying how, when and by whom the existence of such children is ascertained and taking into consideration whether pre-trial detention is necessary (Townhead 2006:18). Furthermore, “the state takes on the responsibility to provide adequate care for the women and their babies” (UNODC 2007: 50). Prisons are for the most part not adequately equipped to offer pregnant prisoners or imprisoned women accompanied by children with sufficiently good living conditions. Pregnancy in prison is an exceptional circumstance. It is hard to get enough sleep, stay relaxed before going into labour and enjoy adequately hygienic conditions.

In some cases the psychological burden is quite heavy on pregnant women in prison, on the account that they have been accused of committing a crime and sentenced, and therefore are separated from their relatives or partner/husband. Instead, they live in a cell with other women, where noise is constant noisy and privacy is restricted. “Pregnant prisoners have “dietary requirements, medical needs and specialised exercise regimes…it maybe difficult to arrange for prisoners to have health care checks and scans, ante natal classes, birth preparation classes and post-natal care” (Townhead 206:46). Access to medical staff 24 hours a day can seldom be provided by the prison regime. Other prisoners might exercise aggression towards a pregnant detainee, as she may receive better care and more resources than her non-pregnant counterparts. This can result in physical abuse or bullying, which may lead to additional stress for the pregnant prisoner.

Pregnant women need specific care during their imprisonment. As mentioned in Chapter 1, a considerable number of women in prison are drug addicts and often have suffered from their addictions for many years. As drug addiction can lead to amenorrhea, it can in fact happen that a pregnancy goes unnoticed until the detainee is tested in connection with beginning substitution treatment. Therefore, it is not only important that a pregnancy is handled in a clinically correct way but also that the mother-to-be has access to psychological support in order help her ease into the new situation of being pregnant and in prison. The pregnant detainee must have the possibility to decide how she wants to handle her pregnancy. The prison should be prepared for treating and counselling pregnant women who wish to go through with childbirth but also to provide them with the option to terminate the pregnancy, if legal.

Another situation arises if a female inmate has suffered a miscarriage before arriving in prison or shortly thereafter, probably caused by withdrawal from previous drug use.

All pregnant women in prison must receive the same kind of pre-natal check-ups as given to pregnant women within the outside community. They must also receive special dietary nutrition which suits their condition. It should be possible for pregnant women to regularly see a nurse/midwife and/or a doctor, and preferably a gynaecologist. Special attention should be given to pregnancy-related health complications such as high blood pressure, diabetes or iron deficiency. The prison should provide whatever medical support is needed to save the lives of the mother and her child.

Transport to the nearest hospital to the prison must be secured – a long journey to a local hospital by way of inadequate transportation is not acceptable and can compromise the health of both the mother and her child. Childbearing women should not need to be left alone during delivery and instead be given the possibility to decide who should be with them during her period of labour. Speedy authorization is to be provided by the prison regime without subjecting

41 the pregnant detainee to bureaucratic or embarrassing procedures. Mothers-to-be in prison should also have the possibility to be accompanied by companions during childbirth. These measures aim to make childbirth in prison comfortable for the detainee as possible. This is important for the child’s future development and for the social rehabilitation of the mother. As prisons usually cannot provide and comply with such measures, the national justice systems should avoid subjecting pregnant women to childbirth in prison this kind of situation. The prison system is often simply not capable of meeting the needs of a pregnant women in terms of both allocating resources as well as providing moral support.

UNODC lists some major rules and regulations that should be followed when pregnant women are imprisoned:

• Women should be transferred to hospitals outside the prison to give birth to a child; • Shackling or any other kind of restraining are inadequate and condemned as inhuman; • Security measures should be limited to the absolutely lowest level needed; • The child should be officially registered right after birth as any other child. The condition of being born while the imprisonment of the mother should not be mentioned in any birth certificate or official document. The child should not have any disadvantages by being born by an imprisoned woman; • The women should receive adequate pre- and post-natal care and that the child profits from the same regular postnatal checkups and participates in e.g. vaccinations plans if applicable; • Breast-feeding should be possible in prison in an adequate environment under clean, silent and relaxed conditions. The prison regimes should be adjusted accordingly.

Many women suffer from anxiety and depression prior to, but more often, after delivery. Therefore, women must have the possibility to see a psychologist/psychiatrist when needed and receive adequate treatment. Children and mothers should have a room where they can live undisturbed by other prisoners and in an environment that is appropriate for babies and small children.

As emphasized by UNODC the mother, not the child, is the prisoner, and accordingly the child should be treated in an appropriate way, having the possibility to play, make social contacts and socialise with other children inside and outside the prison. They should also receive health care, be supervised in terms of their physical and mental development, and receive sufficient support to learn and grow. The mother should have the possibility to be together with her child as much as possible. In situations where the mother cannot be with her child (for some reason connected to the prison regime), the prison must take responsibility for ensuring that other care-givers are in place. It should be possible for relatives to keep in touch with the mother and her child as often as possible. This means that visitation rights should be more flexible and subject to less bureaucracy in these cases.

4.1.1 Women in prison who are accompanied by their children

There are different approaches to the national justice systems on how to deal with the issues of women giving birth or being accompanied by a child while in prison. The most common solution is the creation of a mother and baby unit (MBU).

42 2 RUSSIA 1 LATVIA 1 FINLAND 1 ESTONIA

8 GERMANY

POLA ND 50

Table 2: Number of MBUs in countries in the ND region (Townhead 2006:48, NDPHS questionnaire)

“There is no agreeing optimum time to separate children from their mothers” (Townhead 2006:69). However long a time the prison authorities allow a child to stay with their mother in prison depends on their assessment as to what is best for the child. The prison authorities can easily end up in a moral dilemma when they have to decide what the best solution is for the individual mother and her child. To be separated from the mother will always be traumatic. A crucial question that is often not adequately addressed is a matter of “when does it become more harmful to the child to stay in prison rather than to suffer separation from the mother?” Both the rights of the child as well as the rights of the mother have to be taken into account. However, many children and mothers do not face separation as the latter are mainly sentenced for minor offences and are therefore out of prison after short time. The separation of a mother from her baby should however be avoided when it is not absolutely necessary. “Allowing babies but not older children to reside in prison is based on the premise that the separation of mother and baby causes emotional problems on both sides. But to keep a young child in the limited confines of a prison hampers their educational and social development and thus they should be removed from the prison at a certain age” (Townhead 2006:48).

43 Germany 3 Latvia 4

3 Denmark

Lithuania 3

2-3 Finland

4 Es tonia 3 Poland Sw eden 1

Table 3: Maximum number of years that children can stay with their mothers in prison (Duenckel et.al 2005).28

4.1.2 In practice within the ND area

Poland: There are two „Houses for mother and child”; one in Lubliniec providing places for 15, the other in Grudziądz providing places for 35 mothers. Pregnant women are sent to special maternity ward institution within the regular prison which is situated next to the mother and child unit. On mother's request, she is taken to the mother and child unit with her child, where the baby can stay up to the age of 3 years. If there exist any educational or health reasons the doctor or psychologist can send a written opinion to the special division of the court. As a result court can make this period longer or shorter. While living in the house women are provided with clothes and shoes for babies, cleaning and caring equipment, bedclothes, pillow and duvet for children, blankets, etc. (own research).

There is special staff on site including: a paediatrician, psychologist, nurse, dietician and social case manager. As each mother and child house is situated next to a prison, the house is staffed by personnel from that same prison. If the father of the child has the legal right to decide on the fate of the child (shared custody), he has to agree that he or she can be taken to the mother and child unit. The equipment within the house has to be similar to that found in “normal” housing for small children. The house is equipped with bedrooms for the mothers and their children, providing the minimum private sphere, adequate furnishings for a baby, a shared living room, kitchen, and bath facilities. There are separate rooms for the personnel and medical staff.

Sweden: In 2005, five children were accommodated together with their mothers in prisons in Sweden. The children can stay with their mothers up to the age of 12 months old. Services and care are provided individually, offering the best solution for the child. The average time for children to stay in prison was five months. Prison authorities want to keep the child’s stay in prison as short as possible.

28 Norway: no babies allowed

Russia: Prison Health conditions in Russia differ in general quite a lot from other countries in the Northern Dimension area. Eighty percent of convicted women in Russia are mothers. The average prison sentence is 5,5 years. Only a very small percentage of detainees (one percent) become pregnant while in jail. “As long as the mother is in pre-trial detention facility, she has the baby with her, but as soon as she is moved to a colony, the baby is taken away from her and put into a ‘home for mother and child’, in fact an orphanage which mothers can visit for a couple of hours a day” (Alpern 2002). There are ten colonies in Russia where women are detained “together” with their children, but only one where women actually live together with their children.

The colony no 12 for women in the village of Zaozernyi is situated approximately 15 kilometres from the city of Khabarovsks. It is a general regime establishment for sentenced women with a capacity of 1207 places. A majority of the detainees come from the Khabarovsk area, around 40%. According to the report CPT/ Inf (2003) 30, the colony is the only prison in this region of the country that accommodates female prisoners together with their children. Children can stay up to the age of 3 years. The colony has a baby unit located in a separate building located one kilometre outside the colony with space for 40 children. Accommodation is given in three different sections divided by the children’s ages. There are several playrooms; the units have their own kitchen, garden and a small farm. The children are taken care of by a team of 36 persons, including 3 doctors; 2 of them are pediatricians, nurses, educators and orderlies. There is possibility for breastfeeding mothers to stay together with their child and to be employed in the unit. All babies are born outside the colony in nearby city hospitals.

The CPT reported after a visit to the colony in 2001 that members of the prison staff are present in the hospital room during delivery. In some cases women were not taken to city hospitals but gave birth in the prison hospital. Female inmates who were interviewed by the CPT reported that they were separated from their children after birth and not allowed breastfeeding due to different reasons (syphilis, smoking, long sentences). Alpern reported that escorted visits to the children who were placed in the children’s unit varied from two to three times a week, up to two months of separation. Alpern writes in her article that women who are in the “lucky position” of giving birth outside the prison are separated from their children and escorted back to their cells “only two hours after delivery” as the prison cannot afford to keep the staff away from the prison in the accompaniment of a birth-giving mother. It was also reported that women were not allowed to breast-feed. In addition, “the workers involved in care taking of the children of imprisoned mothers are convinced that convicted mothers do not deserve to be called mothers and should not be cared about” (Alpern 2002).

Latvia: Ilguciema prison (near Riga) is the only women’s prison in Latvia. Women stay together with their children in separate rooms in the mother and child unit until the child is one year old. Later on, childcare is organised by the prison personnel of the mother and child department, which is joint effort of the doctor, nurses and a teacher. Children of the ages one to four are visited by their mothers twice daily, and in total not less than three hours a day.

Children stay in the MBU whereas their mothers live in prison cells. Pregnant women have the opportunity to be scanned in prison. These procedures are monitored by a guard, while no other security measures are taken. They give birth to their children outside the prison. Also, abortion can be arranged up to the legal week and is freely available. Mothers with babies live in a special mothers and babies unit, which is specially equipped for keeping babies up to the age of one year. The unit has space for 6 mothers with up to 20 children. The QCEA observer reported that the facilities in the unit were very good, with enough space for all mothers, individually painted bedrooms with adequate furniture, even curtains and table cloths. The mothers could bring personal belongings, and there are toys and baby equipment at their disposal. From a medical point of view, the unit provides a nurse and a female doctor 24 hours a day and there is also a room reserved for medical treatment. New mothers are kept separately from the others in

45 the unit and have the possibility to learn how to properly take care of their child. The mothers of older children are requested to go to work and to visit their children regularly. Older children have a separate dormitory with additional equipment such as toys and furniture. The unit is run by an American church group that also teaches Montessori-based rules. A garden providing space for play is also a part of the unit. Nurses ensure that the older children receive proper nutrition. The unit is drug-free (QCEA 2005, fact finding visit to Ilguciema).

Denmark: Horserød prison is the second biggest in Denmark with 221 female inmates. The QCEA observer reported the following: “The prison provides a family unit with fourteen beds for parents with children of less than three years of age and for married couples where both parents are sentenced. There is one cell for a couple with children, consisting of one cell for the parents and one connected room for the child. Before coming to prison the sentenced parent receives a letter when to arrive in prison so that they have the opportunity to make arrangements for children and thereby having more influence in who will take care of the child during their imprisonment. Mothers have the choice to bring their babies if they wish to. The family unit is strictly separated from the other prison units in order to provide security for the child and to keep the unit drug-free. Mothers are not obliged to work when they are accompanied by their child, but if they wish to work, the child has the possibility to go to kindergarten. Children have the possibility to see family and friends outside the prison upon request. Mothers can take their children out of the unit and visit other prisoners with their child. There is no qualified childminder or a nurse, the effect of prison on children is not further monitored by any measures and a trade-of appears if the mother wishes to undergo special drug treatment in a separate unit as the child has not access to this unit” (QCEA 2006, part II, country report Denmark).

Estonia: According to QECA “the only mother and baby unit in the country is in Harku women’s prison and pregnant women and imprisoned mothers with children are transferred to Harku” (QCEA 2006, part II country report Estonia). Consequently separation is poses a problem to maintaining family ties because of the long distances between the prison and the sentenced mother’s home.

The unit was established in 2001, and is located in the same building as the medical department. The facilities consist of three rooms, a kitchen, two bathrooms and two toilets which are modern, renovated and furnished according to the needs of small children. At the moment there is a space for up to four mothers accompanied by their children. Age and gender differences of children will be kept in mind when housing them.

This unit also functions as a facility for pregnant women. Pregnant women are transferred to civilian hospitals for childbirth. After birth, mothers can keep their babies with them 24 hours a day, to be able to breastfeed and care for them generally. Mothers who are in prison can live together with their children until the child reaches the age of four. This guarantees the children with a living environment that will cause them the least amount of harm and will promote their normal development. There is a playground on within the prison for detainees’ children.

There are certain benefits for mothers who are living separately from other prisoners, such as access to more comfortable living conditions, possibilities to cook, etc. Mothers, who live in this unit, receive foodstuffs have to prepare meals for themselves and for their children. They receive advice from the prison medical staff and social workers. Mothers are guided by a social worker who ensures that the activities which they engage in with their children are in accordance with their needs and appropriate for the child’s development. Necessary equipment for children is provided by the prison, for example: books, means for handed and kinetic activities etc. Besides that, mothers also have the option to buy equipment and clothes for their children.

46 Older children have a possibility to go to the local kindergarten outside of the prison, where they will play and communicate with other children who are their own age. Mothers will escort their children to and from kindergarten daily.

Fathers are able to meet with their families during short and/or long-term visitations in accordance with the regulations of the Estonian Imprisonment Act.

All children in Estonia, regardless where they live have medical insurance from the Estonian Health Insurance Fund.

Estonia: Tartu prison does not have a mother and baby unit. Sometimes pregnant women in need of special antenatal care are kept on remand in Tartu prison. They can give birth in a civilian hospital. However, before the time of birth, the pregnant female prisoners “do not usually have to leave the prison for external medical appointments as there is an ultrasound suite in the prison medical department” (QCEA 2006, fact finding visit to Tartu prison). Near the time of the birth the medical department makes preparations for the prisoner to go to the civilian hospital. A social worker assists the pregnant woman, for example in cases where the mother has a long sentence and the child must therefore go to an orphanage. It is a general rule that the child’s birth certificate has no note from the prison.

Lithuania: In 1994 Panevezys Correction House opened an Infant Section. Accommodation is provided for women with babies born while their mothers were kept in pre-trial detention or in the Correction House during the imprisonment. Since 2003 this applies to mothers who gave birth to their babies before conviction. The children can stay together with their mothers if this is in the best interest of the child, and the child can stay until the age of three. The mother can afterwards choose either to place the child with her family or to keep the child in the Correction House. There are double rooms for mother and child in the unit as well as playroom and commonly used living conditions.

United Kingdom: In England a small charity group carried out the so-called “Doula project”, which consists of a small group of teachers and student teachers who accompany a woman during her pregnancy in prison. They can even support her during her delivery in prison if she wants them to. These projects provide a contact person outside the prison for the sentenced woman who helps her to stay in contact with the outside world and supports her in any matters regarding pre-release training; they can be with the prisoner during the pre- and postnatal visits and assists her with all post-natal care. A similar project of the charity group works on the basis of birth companions who give support to women who undergo childbirth while in prison. The charity has e.g. a small group of part time devotees going to prisons in order to visit and support the women in pre- and postnatal care. They draw up birth plans and help young mothers adjust to their new role as mothers. The setting up of birth companionship can be a good practical example from outside the Northern Dimension area, which might be worth adopting for female prisons in the ND area.

4.2 Women with children outside the prison – social well-being and prevention measures

In most of the ND countries, the legal custody of a child is with the mother. The children of imprisoned men mostly live with their mothers who are maintaining the relationship between the father and child and other family members. The average imprisoned women is single and has to take care of her child by herself, either by taking he or she into custody or by finding a caregiver for her duration of imprisonment. Due to a lack of close ties to family members of friends, the child is in danger of ending up in the care of foster families or foster homes. In an international study on women’s imprisonment (Duenckel 2005), it was shown that (out of the sample chosen) children of imprisoned women mainly stayed with their grandparents for the duration of their mothers prison sentences.

50 47,6% 45,2%

37,3%

32,2%

30 Mean Lithuania Poland Rus sia Germany

Table 4: Percentage of children who are staying with their grandparents while their mothers are in prison (Duenckel et.al 2005).

The rather low percentage in Germany is caused by a high percentage of children staying with their fathers when their mother is in prison. This was the case for 37,3%, compared to only 8,6% in Russia. An alternative to staying with the father or a grandparent is the possibility of staying at children’s homes.

25,7%

15,3%

9,5% 10

5,1%

0 Mean Lithuania Poland Russia Germany

Table 5: Percentage of children who stay in children’s homes. (Duenckel et.al 2005).

48 It is important to mention that in Russia only 2,9% of the children of imprisoned women stay within the care of their families. Instead, most are placed in children’s homes, however in Lithuania 18,6% of the children stayed in care of their families. This number was even higher than the number of children staying in children’s homes and with their fathers.

Out of the 2000 imprisoned women in the Northern Dimension area, 60 have children under the age of 18. Ten percent were kept together with the mother in prison depending on the age of the child (mostly very small children stay with the mother during her imprisonment). Forty-five percent of the children stayed with relatives other than their fathers. Five percent were taken care of by the father himself and an additional 20% were placed in foster homes or in the care of others. The imprisonment of the mother poses a challenge to the child’s life structure as well as to their social and personal development.

Children suffer from being separated from their mothers and from the social structures that they are accustomed to. Many of these children are present at the time of their mother’s arrest and often cannot comprehend the situation. Many have experienced being separated from their family members in the past, resulting in feelings loss, betrayal and insecurity. Depending upon their age and when they live in the ND area, a child may understand and deal with the situation of having the mother in prison differently.

During their first year of life a child is not expected to react to the situation of their mother being in prison. This is why the childbirth in prison is widely accepted in the national prison systems throughout the ND area. However, during its first months of life, a child develops a certain connection to its mother. He or she learns to trust her and to communicate its needs to her. As reported in the American study on children in prison: “if a primary caregiver ‘disappears’ by going to prison it will seriously interfere with the development of trust” (www.fcnetwork.org, CLP 301) of the child. The child can sense that a parent, especially its mother is not present or even inconsistently present. Very young children develop a sense of being betrayed in terms of their opportunities to develop a close connection to the mother, as it is not really possible to substitute this special relationship with other care-givers.

Children between the ages of 1-2 years (toddler) want to grow even closer to their parents, and especially to their mothers. However it is also during this time that they begin to show tendencies towards independence. Their verbal and motor skills begin to develop, as does their desire to explore their worlds. At this time, they still of course need to be taken care of and are still highly dependent upon their mothers for this care. Children who are testing the limitations of parental control need guidance but also need to be said “NO” to. If this type of guidance and structure cannot take place on the account that the mother is in prison, “caregivers of children of prisoners pour emotional and physical resources into managing life in the criminal system and have little left for coping with a toddler’s extreme upsets and shifting mood”(www.fcnetwork.org, CLP 101).

It often happens, mostly to children at a certain age, that they feel somehow responsible for the fact that their mother is in prison. This is similar to the way in which children of divorced parents often believe that they themselves are the cause of the separation. Such feelings of guilt and/or shame result in an additional psychological burden for children of imprisoned mothers, and no doubt hinders their ability to develop in a normal, healthy way. This problematic tendency will be addressed later on in this Thematic Report, in the on chapter focusing on criminal behaviour among juveniles.

“Research from many countries has revealed that when fathers are imprisoned, generally the mother continues to care for the children. However, when a mother is imprisoned, the family will often break up, resulting in large numbers of children being institutionalized, in state care” (UNODC 2007:13).

49 “There are different traditions in respect to the contact that prisoners are allowed with other family members.”29 Children who are given visitation rights should have the possibility to freely move around in the visitors’ rooms, apartments and playgrounds on the prison grounds. They should also have the possibility to see how their mothers live, which includes being able to visit their mothers’ room/cell. It is known that children develop their own ideas about what their mothers’ lives are like inside a prison, especially when they are at a certain stage of their own development. Many children experience feelings of worry as to whether their parents are badly treated or suffer physically or psychologically while living in prison. Having the possibility to visit them and participate in their lives even while they are serving their sentences helps the children of detained parents to overcome their fears and better cope with the situation.

Children are allowed to visit their mothers in prisons within Denmark, Finland, Germany, Norway, Poland, and Sweden. In most of the countries, prisons have special visiting rooms and/or small apartments for overnight stays. Prisons make special arrangements for allowing extended visits and also provide visiting children with toys and books (Poland, Sweden, Norway, Finland, and Denmark). Only in Germany are more frequent visits by children allowed, however overnight stays or extended visits on weekends are not permitted. Countries like Estonia and Latvia do not have special arrangements for children visiting their mothers in prison.

When it comes to family visitation, a balanced approach should be taken to assessing what is best the child of an inmate. Some women are serving prison terms for committing crimes against family members, in which case they should not be allowed visitation by their child/children. These women need special therapy, which requires the involvement of care- givers, social services and well-educated staff members who are able to handle detainees with mental health issues. “Visits present logistical and security challenges for prisons, particularly in terms of staff time. This is increased for special visits such as family days” (QCEA 2007, part 1). The justice system and prison regime face many different challenges if children are to be allowed to visit prisons. Mothers can refuse to see their child if they think that it may be too disturbing for the child or because they will need additional security measures. Children may not have the developmental ability to understand what prison is and why their mother is being detained, which can negatively impact the way that her or she interacts with his or her mother during visitation. There may not have access to visitation rooms or such rooms may not be suitable to host children for longer-term visits. Their visits to prison may also require long periods of travel, making overnight stay a necessity in which they also need to be accompanied and supported by an adult. Certain aspects of prisoners’ social rehabilitation and reintegration, and their connection to family visitation will be outlined in Chapter 5.

Most women have legal custody of their children until they reach the age of 18. This creates additional stress for mothers at the time of their arrest, because they must also find appropriate care-givers for their children, who are both trustworthy and capable. During their imprisonment, women are often worried about their children. Therefore it is of utmost importance that the mother is given the possibility to remain in contact with their child/children, for example by ensuring regular visitation and guidance on how to keep family ties intact. Many women worry about the future of their child, and suffer from feelings of guilt and/or shame on the account of being in prison. This is a major issue addressed during prisoner rehabilitation. Measures should be taken to avoid a situation in which the child follows on their own feelings of separation and guilt, to later engage in juvenile criminal behaviours. Many studies demonstrate that the female prisoners with a child living outside the prison endure a particularly high level of stress. This stress stems from feelings of loss and guilt, because they have not managed to act as a stable force in their children’s lives, and because they are not able to participate in the every day life of their child. They also may blame themselves for the stress and anxiety felt by their child. Therefore, it is important that imprisoned mothers have the chance to participate in their children’s lives so that they may continue to be a part of it. Such an

29 European Society of Criminology, newsletter April 2007, page 12.

50 arrangement guarantees better social rehabilitation on the part of the prisoner, as she will have a life of caring for her child to look forward to upon being released. While still in prison, it should be possible for the mothers to participate in important events of their child’s life, such as birthdays parties, their first day at school or parent-teacher meetings. Otherwise, feelings of guilt and shame will put a successful rehabilitation and reintegration at risk.

It must be possible for the detained mother influence the decision on who is going to take care of her child while she is in prison. She will need to receive regular proof that her child is in good care, either by having the opportunity to examine their well-being during visitation or by receiving updates from visitors who they trust. As a minimum, she should be entitled to regular contact with her child via mail and telephone. Many prisoners who have children experience difficulty in explaining to their child where they are, and why they cannot be “at home” with them. On of the reasons why it is so crucial to ensure regular contact and visitation between the mother and her child is to avoid a situation in which the child believes that his or her mother is missing or even deceased. Several studies illustrated that it is best for the child if the mother is able to explain on her own why she is in prison, in order to foster feelings of trust and security vis-à-vis her child. If the child learns about his/her mother’s imprisonment through a second or third source (i.e., by relatives or the media), there is a chance that mother-child trust might be compromised.

It is important that imprisoned women who have children are able to continue being mothers – this family role should not be taken away on the account of her imprisonment.

Having the possibility to see the child regularly can also produce stress for a mother in prison. Some studies show that these women suffer from depression and anxiety following their child’s visit, as it is during that time that they experience a heightened sense of loss and guilt/shame. They may feel a loss of being able to see their child growing up, and that they have ruined the possibility of enjoying a close relationship with their child. They may also blame themselves for not being good mothers, and thereby, experience feelings of being inadequate women and having low self-esteem. Such feelings led to depression and self-hatred, which can further result in self-inflicted harm and even thoughts of committing suicide. Many women are stigmatised for being criminals and for also abandoning their responsibilities to their children and families. This double-stigma of being criminals and “bad mothers’ may make it even more difficult for convicted women to reintegrate into society than their male counterparts.

One outcome of the depression, low self-esteem, feelings of loss, and stigmas that mothers in prison suffer from is their heightened aggression towards officials both inside and outside the prison. Many women have a distinct need to talk about their problems and feelings however, any productive communication requires time and specially educated staff (which most prisons do not have). The prison regime must take women’s approaches to conflict-management into account when arranging for psychological treatment. This is also because female conflict- management differs from men’s, especially when it comes to dealing with family problems and social stress.

4.2.1 In practice within the ND area

Eastern European Countries: “In general, it can be said that the Eastern European countries have the most human approach, where sentenced prisoners may receive private visits from their spouses, partners, and families at a regular basis, for a period of up to three days. These visits take place in small flats within the prison and visitors bring sufficient food with them for the

51 period. There are usually communal sitting, cooking, and children’s play areas and up to a dozen separate bedrooms for prisoners and their [relatives]”.30

Estonia: At the women’s prison in Harku long-term stays for children and family members are possible for up to three days every six months. These longer visits can take place with the spouse, parent, child or other closer relatives. Young children have the right to physical contact with their mothers.

Norway: At Bredtveit prison in Oslo – the biggest prison for women in Norway with 59 places –a visiting apartment is available where a mother and her child can spend time together. Overnight stays are possible. The mother and child must receive permission before spending time in the apartment, and must have already had visits together in a visitation room. The prison staff makes sure that the relations between the mother and her child are acceptable. The mother must also participate in a course on parent counselling. The apartment is equipped with kitchen, two bedrooms, a living room, and a bath. The purpose of the facility is to give the mother and child an opportunity to live a “normal” life together, and share ordinary experiences like preparing their own food, etc.

4.3 Criminal behaviour of youths

“Research has also indicated that the children of imprisoned mothers may be at greater risk of future incarceration themselves” (UNODC 2007: 13).

As recognized by Greene, Haney & Hurtado 2000:3f “children are profoundly affected by their mothers´ incarceration. Many will suffer feelings of fear, guilt, rejection, shame and loneliness. Studies have identified poor school performance and aggressive behaviour in children of incarcerated parents. In addition to the loss and instability that the incarceration of their mothers brings, many children may be vulnerable because of the risk factors to which their families´ difficult life circumstances have exposed them. Many of them may have experienced the very criminogenic factors that contributed to their mothers´ incarceration, giving rise to a cycle of criminality.”

Any report concerning pregnant women and women in prison accompanied by children should not only deal with this issue in terms of health (mainly) from the mother’s perspective, but should also take into account the social-well being of the child. In giving credit to the children and involving them in health and social well-being plans for their detained mothers, the justice system and prison regimes contribute to prevention, thus saving them from similar patterns of criminal behaviour. Just because their mothers are in prison, does not mean that the children of detained females will follow in the same pattern in life. On the contrary, the justice system and prison regimes can play a major role in working against this social bias and stigma. It is indeed an unfortunate case that the children of imprisoned women are often the forgotten victims of their mothers’ crime(s).

The experience of having a mother in prison can result trauma, however it can also come as a relief for children that their parents can no longer hurt themselves or others. However, data on children in prison and the influence of having an imprisoned mother has not been thoroughly analysed. The Quaker Council Europe recommends that, “States should keep and provide disaggregated data on women and girls in prison and pre-trial detention […]. States should systematically collect age and gender disaggregated data on babies and dependent children of all persons held in detention or in prison […]” (QCEA, part 1 2007:19).

30 European Society of Criminology 2007:12.

52 Sentencing may result in the limitation of certain rights, but it should not impact the rights of the offenders’ children. These rights are often not considered when dealing with offenders. “The application of the principle of the best interests of the child seems, in fact, to be far from incorporated in the decision-making process regarding children of persons deprived of their liberty…In addition, the frequent dilemma between the rights of adults and children, in particular between the rights of women and the rights of the child, seems often to remain unaddressed and unresolved” (QUNO 2005: 48).

According to the Quaker Council of European Affairs the imprisonment of the mother can have affects on young children. When looking at the social background of juvenile prisoners, there are a number of factors that make some young people more likely to end up in prison than others. These factors are:

• A range of psychological problems such as depression, hyperactivity, aggressive behaviour, social withdrawal, regression and general delinquency, clinging/needy behaviour, sleep and eating disorders, truancy, poor academic performance and attempts to run away from home; • Symptoms including feelings of desertion, abandonment, and rejection on the account that their parent(s) are not present; • Financial desperation due to a loss of family income resulting from the imprisonment of the mother.

The following are additional risk factors for the children of inmates that can come about as a result of their incarceration (www.fcnetwork.org, CLP 301):

• Abuse • Poverty • Racism • Substandard schooling • Alcoholism • Drug addiction • Deteriorating/ uninhabitable housing • Gang involvement • Crime-victimization or criminal activity • Trauma • Parental neglect • Low nutrition • Inferior medical care • Mental illness • Physically or emotionally unavailable parents • Marital distress/divorce • Single parenthood • Lack of social support and role models • Deprivation of social relationships and/or activities • Profound repeated loss

It is imperative that both the parents as well as the children are protected against these risk factors during and after incarceration. Also, child-care givers must ensure that measures are taken to protect the child from any of the risks listed above. Having an imprisoned mother can result in various serious consequences for children, both socially and psychologically.

As children might possibly be present when the mothers were arrested, and perhaps even witnessed violence during the arrest, they sometimes experience feelings of being powerless.

53 They perhaps have the impression that representatives of law enforcement are indifferent to their interests and security, which can lead to post-traumatic stress, attention deficit disorders and attachment disorders. After their mothers’ arrest, children who cannot be cared for by their fathers or their close family members might be forced to enter foster homes. Foster arrangement can also entail multiple placements for the child, increasing the risk of abuse. Such scenarios are often considered to form the basis for criminal behaviour during adulthood.

”For many prisoners parents’ rage, depression and addiction is and has been a part of life followed by the criminal activity and own addiction” (www.fcnetwork.org/ CPL 301). The Canadian NGO “Voices for children” http://www.voicesforchildren.ca/ conducted a study, supporting this Thematic Report’s position on children as the “invisible victims” of an imprisoned parent. They listed factors that play a role in how parental incarceration – especially in the case if the mother – impacts the physical development of a child and contributes to the likelihood that they become later imprisoned (probably also having their own children outside or inside the prison):

• Unhealthy coping strategies. Coping strategies in general help children of all ages deal with hurtful situations. Children who have a mother in prison experience disruption, anxiety over the future, shame, and other difficulties such as violence or poverty.

• Rationalization is a particular coping strategy which children use to preserve their image of mom as a good person. They tell themselves that people who say bad things about her must be wrong or confused or malicious. Children might even begin to see crime as necessary and noble in some circumstances

• Living in poverty is an extreme strain on children whose mothers are imprisoned. They are affected by the stresses and strains of life in disadvantaged neighborhoods, subsidized housing complexes with high crime rates, poor nutrition and an ever-present sense of want.

• Freedom from adult supervision and guidance is another factor that may lead to criminal behavior in young people whose mother is in prison. Whether they choose to accept it or not, adult guidance allows adolescents to grow and develop within a safe environment.

• Stereotyping by decision-makers within the justice system is also a problem if children are pre-judged based on the criminal involvement of their family members, which might lead into a situation of self-fulfilling prophecy, where the child is expected to become a criminal and final just fulfills the expectations if the society.

The imprisonment of women, and especially mothers, should be avoided in order to break the vicious circle of the multi-imprisonment of several generations within the same family.

Chapter 5

SOCIAL REHABILITATION AND PRE-RELEASE TRAINING

Photo by Juerg Christandl

5.1 Background

“It is essential for inmates who have become a vulnerable population that they should be educated, treated and empowered”.31 In the international study on women in prison conducted by the University of Greifswald in 2005, the authors point to the fact that access to activities, especially education and vocational training is a major challenge for female prisoners. This type of access should not be restricted by the fact that women are not detained separately from men, but rather they are in male prison “annexes”. Furthermore, as argued in Chapter 2, education and activities should not force women into typical female work, but be gender equal, appropriate, and for the good of the prisoner’s (male or female) reintegration: “[…] cleaning, kitchen duties and handiwork” (Duenckel 2005: 11) is therefore not acceptable work or training for detained women.

Observatoire Internationale des Prisons (OIP)32 demonstrates that a high percentage of prisoners are illiterate or have received only very basic education. Many women come from marginalized families and socio-economic sectors, and have thus suffered from discrimination and poverty. Most of them committed their first offence because of their poverty-stricken situation. Several women in prison have a history of abuse and have been unable to change their living situations due to lack of financial/material resources. In many countries, girls are still not offered access to education to the same extend that boys are.

31http://www.steppingstonesfeedback.org/downloads/Using_SteppingStones_in_an_Indian_Prison.pdf). 32 http://www.oip.org/.

55 A survey conducted in 2002-2003 by Christine Friestad and Inger Lise Skog Hansen in Norwegian prisons reveals33 that the most common living conditions before imprisonment (for men and women) include:

• Lack of a social contact (no prison visits in the last 3 months); • Unemployment (was not employed during the time of conviction); • Health problems (has a chronic disease which negatively impacts their quality of daily life); • Lack of education (only attended elementary school); • Problems with housing; • Economical problems.

Thirty percent of the women and men surveyed had none of the problems listed above. Thirty- five percent had two or more of the problems. There was a tendency for women to have a heavier concentration of problems than men. Three times as many women as men had three or more of the above listed problems.

Among the selected persons surveyed, it was found that in the case of women:

• Almost all of the women were unemployed at the time of conviction which makes them especially vulnerable in the labour market;

• Around 50% had an insufficient level of education (only elementary school as the longest completed level). In the general society, this figure sits at 10%;

• Between 40% to 50% suffered from health problems In general society this figure sits at around 25%;

• More than one-third had problems with housing. There are big differences between the statistics for inmates and persons in general society in relation to their respective levels of education, with completely diverging tendencies. Most of the prisoners surveyed had:

• Elementary school as their longest completed level of education. Four out of ten had only completed junior secondary school and very few had any education beyond advanced secondary school. • Difficulty reading and/or writing. • No occupation or an occupation that did not require any education. • Employment not extending beyond one year. Only three out of ten were employed at the time of their imprisonment.

And again, three times as many women as men had three or more of these problems. Also, two- thirds of the inmates had an adolescence marked by one or more of the above-mentioned problems.

The majority of the inmates indicated that the main source of their income was derived from the social security system and criminal offences such as petty theft. Taking this into account, the European prison rules clearly state that there should be education and employment for women in prison in order to guarantee their successful rehabilitation and re-integration into society after release: “Women must have access to diverse types of jobs, and true choices should not be limited to jobs which are traditionally considered feminine.”

33 Friestad, C. & Hansen, I.L.S. (2004) Levekår blant innsatte. Fafo-rapport 429. Oslo: Forskningsstiftelsen Fafo

The UNODC warns that typical female education programmes “impose the role models on women, which exist in society, thereby failing to help them overcome the restrictions imposed by stereotypical perceptions” (UNODC 2007: 34). This means that rehabilitation and vocational training must follow a gender equal approach, aiming at increasing women’s opportunities in the job market after release from prison. Programmes should support female detainees in becoming able to make a living based on their new professions or their new skills, thereby ensuring their successful reintegration into society and helping them to regain self-confidence.

UNODC suggests the following types of vocational training:

• Administrative skills as bookkeeping, computer skills; • Creative skills including painting, decorating, hairdressing, dressmaking; • Gardening, horticulture, electro technology; • Women’s health and childcare.

Another issue is the unequal payment for work inside the prison and a noticeable gap in salary levels for female and male prisoners. This should be avoided and gender equal measures should be taken into account. Otherwise, work in prison may result in the loss of self-esteem in the case that detainees see that they are not remunerated at the same level for the same work. When women are detained in the same prison as men are, they should receive access to separate educational and work facilities and special gender-tailored programmes.

Successful social rehabilitation depends upon the type and quality of the prisoners’ activities and programmes, as well as the extent of the prisoner’s access to them. UNODC points out that, “Activities and programmes should first of all prevent recidivism.” Furthermore, education and vocational training make it possible to establish close working relations with organisations from outside the prison system such as NGOs. Many countries and prison regimes, e.g. in Russia, do not always react positively to the work of NGOs in prisons. But NGOs can make a difference in the quality of social rehabilitation where authorities do not have the resources to provide adequate programmes.

Another solution to the general problem of a lack of resources is peer education. In this case, selected, educated prisoners organise self-learning and educational classes for their fellow inmates. The prisoners who are leading such peer education sessions gain teaching experience and enjoy the feeling of being somehow useful to the prison community. Prisoners who are taught by other inmates gain knowledge and skills (i.e. literacy skills) and enjoy comfortable learning “among equals.” Establishing peer self-help group in prison under the supervision of an NGO volunteer or a social worker can encourage prisoners to become active in educational/vocational programmes, overcome low self-esteem, and develop their own programmes tailored to women’s needs. The latter is especially important as these women are in touch with their needs to an extent that most people are not.

In general, UNODC suggests that prisons should offer programmes:

• To build confidence and life skills; • Parenting programmes; • Psycho-social support, therapeutic programmes, self-help and consultation for cases of drug-abuse, trauma, and violence.

“Prison administration should make every effort to involve local civilian agencies and NGOs in providing activities for women prisoners” (UNODC 2007:7) and furthermore it has to be taken into account that “Programmes that stress rehabilitation, allows the offender an opportunity to re-enter society as a responsible and productive citizen. [If there is no possibility for education and personal development in the prison, inmates] are released back into the same environment from which they came from, without any skills or education to change their situation” (Schwartz 2001).

“Illiteracy in prison is an overlooked issue. The number of illiterate people within the imprisoned population is usually quite high.” (www.educationinprison.org/regionalnetwork/offenders.php).

Education should be seen as being part of social well-being and a key factor in successful social rehabilitation. The family of the detainee should be included in their education and rehabilitation activities as well. Education in prison.org suggests the following measures to include the family of the detainee in educational interventions:

• Preventive psychological work focusing on family (probably in connection with different forms of abuse that appeared in the family); • Promotion of family participation in the detainees activities inside the prison (that requires that the prisoner is placed in a prison close to the family home); • Counselled interventions on the family level right after the release of the prisoner to help the process of reintegration of the prisoner; • As most rehabilitation programmes are tailored for prison contexts not for family community contexts that are not sustainable after release, new measures for this scenario should be found; • Special arrangements should be found for cases were several family members are imprisoned.

In a comparative study from Belgium and Portugal, its author Claudia Resende (Resende 2006) develops a chain of rehabilitation steps in prison, starting from individual rehabilitation to social rehabilitation to re-adaptation. In the first stage, the individual rehabilitation, the following types of competence have to be developed:

• Endogenous competence: self-control, assertiveness, resistance to frustration, and a sense of responsibility. • Technical competence: reading, fluent language and trainings. • Social competence: inter-personal skills, conflict management, and respect for others. • Competence towards risk behaviour designed for different risk groups as drug addicts, HIV/Aids infected. • Cognitive behaviour.

During the second phase of social rehabilitation, prisoners must learn how to reconnect with their families and the labour market. The prisoner must have e.g. the possibility to prepare for employment interviews, establish contact with the outside social-cultural dimension of life outside prison. This grants them access to sport facilities, literature, theatre performances,

58 music and exhibitions. The prisoner might also establish contact with communities outside the prison, which aids their reintegration to society after their release.

These two concepts will lead to the re-adaptation of social skills, which should result in their successful reintegration in society. Managing life outside the prison does not only depend on what kind of individual resources and living conditions are available – it has also depends on what kind of conditions society can offer. Reintegration is only possible if the efforts offered inside the prison are met by a healthy the structure in society at large.

5.2 In practice within the ND area – Estonia, a case study

This chapter will take a closer look at education, social rehabilitation programmes and best practices based on experiences from Harku female prison in Estonia.

5.2.1 Individual Sentence Plan34

In order to evaluate the social-economic situation and the dangerousness of prisoners, a re- offending risk and needs assessment instrument has been developed and implemented. The instrument is common for prison and probation. Outcome of the risk assessment will provide input to the individual sentence plan (ISP).

The purpose of the ISP is to plan how to work with the individual detainee: to determine the chances to reduce his/her risk of recidivism (the need for education, ability to work, professional skills, etc.) and to draw up a timetable for implementing these measures. The ISP is reviewed once a year (once in six months in case of young detainees) and changed if necessary. The ISP is the basis for the prison and the prison department to decide in which prison the detainee will be placed. The ISP is developed for every inmate who is sentenced longer than one-year period.

5.2.2 Employment

According the Imprisonment Act, all convicted prisoners under the age of 64, who do not have any medical contraindications, are obliged to work. Prisoners who are acquiring education and prisoners who are raising a child of less than three years of age are also released from mandatory work.

Working prisoners are divided into two categories: prisoners engaged in the maintenance work of prison – support staff, cleaners, kitchen helpers etc.; and prisoners engaged in production.

In 2001 a state company - Public Limited Company Estonian Prison Industries – was established in order to increase the employment of prisoners, competitiveness of the production and to decrease the expenses of prisons. The Company organises prisoners’ engagement in

34 Estonia implemented this system from Canada. Canada is seen of having one of the most progressive correction systems in the world. Concerning female prisoners, Canada has six houses for women in prison complexes, also offering a healing lodge for Native American women, non-traditional job training off-site, a trade school which is certifying educational trainings and prison tattoo parlours in order to control the spread of communicable diseases. According to the Canadian prison strategy, there must be a correction plan individually developed for every woman coming to prison. This plan includes education, addiction and medical treatment, parenting classes and finally the last three months of training in non-traditional jobs. Prisons additionally offer regular classes in anger management, behaviour modification, cognitive therapy and domestic violence prevention. www.drug-rehabs.com/female- inmates.htm.

59 production works. The Company provides three main jobs for female inmates: sewing, completion and packing of goods. Currently, about 90% of women in Harku prison are working.

5.2.3 Education in prison

The aim of providing education is to prepare the prisoner for release by supporting the comprehensive development of personality and increasing the ability to cope. The development of the organisation of studies is based on the Recommendation of the European Council “Education in Prison”. Education in prison is organised by the Ministry of Education and Research.

There is a possibility to obtain basic and upper secondary education and vocational education in Estonian as well as in Russian language. The most common areas of vocational training are metal- and woodwork and sewing. Prisoners who are acquiring education are released from mandatory work. Prisoner may also apply for a permit to study outside the prison. With the aim to integrate non-Estonians into the Estonian society, prisons organise courses of official language and citizenship studies. The study work is supported by the prison’s library.

With the purpose to improve co-operation between the prison and the school as well as counsel the prisoners in the education-related questions, a position of education organiser has been created in all prisons. Hobby-oriented education and cultural and sporting events in prisons are arranged by free-time counsellors.

General education

Education in prison is part of the state education system that provides:

• General basic education • Upper secondary level education • Vocational education • Short-term vocational skills courses • Estonian language courses for foreigners

On September 1, 2007, scholarships for prisoners to study became available. Currently the system offers Estonian language courses. In 2008/2009 it will include additional categories as well. The changes are already visible, and the participation in courses has increased and become more stable. The quality of education has improved after prisons have started to outsource the service.

During 2006/2007, 23 students began general education and 70,5% of them completed studies in Harku prison. During 2007/2008, 25 inmates started general education.

Vocational training

Vocational training is one possible means of re-socialisation. The completion of studies may ensure work in the prison and within the general society after release. During 2006/2007, 18 inmates participated in a sewing course. Out of these participants, 81% completed their studies. Two students completed the whole course and the rest partly completed the. During 2007/2008, 12 inmates started vocational training.

The vocational training system in prison is quite flexible and based on the needs of the prisoners. Prisoners themselves may choose whether they want to take a whole course or study only individual topics which they consider necessary. Prisoners, who receive allowance for their

60 studies have displayed more interest towards improving their education. Participation in courses has overall become more stable.

5.2.4 Rehabilitation Programmes

Lifestyle training

The general objective of the Programme is to reverse the habit of using addictive substances. The maximum objective of the Programme is to cure addictions to substances and/or gambling. The minimum objective is to gain control over its use and/or gambling.

The Programme is designed for prisoners who abuse or are addicted to substances (incl. narcotics, alcohol, tobacco, prescription drugs) and gamblers whose addiction to gambling causes unlawful behaviour. The Programme can be adjusted according to the mental health welfare system, probation supervision, and to penitentiary institutions.

During the Programme:

• The motivation levels of the participants are increased; • The harm caused by addiction and the benefits of overcoming it are shown; • The correlations between the use of addictive substances and unlawful behaviour are analysed; • A training plan is drawn up and self-control training is held; • Participants learn how to cope with addiction and social pressures; • Participants learn how to avoid relapses and how to cope with them.

Way of Life Training may be carried out individually or as group work. In the case of individual work, it consists of six to eight one-hour meetings once a week and in case of group work, it consists of eight to ten meetings once a week, lasting 1.5 hours. In case of group work, the group leaders should meet the participants individually four or five times to discuss homework.

Social Skills Training

The Programme is designed for offenders who have difficulties expressing themselves, and analysing their thoughts or behaviours in their everyday life.

All of the offenders need to develop their social skills. Neither the form of punishment, type of crime, nor the length of the punishment is decisive as whether they should participate in the Programme or not. It is important that the participants do not have psychiatric problems or drug or alcohol addiction. It is equally important that all the group members speak the same language and are in the same age group.

Training may be held both in open and closed groups. In case of open training, the participants may join the group at any time. In closed groups, all the participants take part in all the meetings from the beginning. The length of the Social Skills Training is ten hours during two months. Each meeting lasts 1.5 to 2 hours depending on the number of participants.

During the Training, the participants learn to:

• Listen • Start a conversation • Communicate with authorities • Say no

61 • Control their anger • Respond to anger • Stand up for themselves • Cope with conflict situations • Make choices and negotiate • Express criticism • Receive criticism • Present themselves • Express recognition • Respond to recognition

It is not possible to teach social skills academically. This learning can only be based on life situations and experience, applying methods of active learning: narration’s of the teacher, conversations, discussions, brainstorms, role-plays, dramatisations, imagination tasks, decision games, case studies, self-analysis, teaching peers etc.

5.2.5 Preparation for release

This Programme is targeted at inmates who will be released within the next six months and have not received the skills and knowledge which are necessary in order to cope with the life outside the prison.

The purpose of the Programme is to give the inmate the knowledge and practical skills for how to independently find a job and a place to live, as well as how to face other social challenges. Lectures are given once a week during a two-month period. After that, short-term field trips will take place.

The main idea behind this course is that the representatives from The Social Care Centre, the specialists from The Labour Market Board, and the local administration will give presentations to the inmates in order to enhance co-operation with the various prison institutions and to guarantee pre-release consultation to prisoners.

The lesson learned during the Programme will be fixed through short-term field trips along with a social worker. Other prison departments will co-operate with each other in selecting those inmates. They must have participated in the Programme beforehand. The plan for the field trips will be based on the notion of replacing the theoretically acquired “know-how” with practical skills. To give an example of such a trip, the following activities could be carried out:

• Using public transport; • Visiting a bank (opening a personal account, introduction to using an ATM); • Visiting the Tallinn Labour Market Board, getting acquainted with the necessary documentation; • visiting a cafe (behaviour in a public place); • Getting an ID card; • Museum visits; • Summaries, suggestions for independent activities.

Feedback

A questionnaire was compiled in 2004 to get feedback from the Programme participants. The answers showed that all of the participants wanted to take part in similar courses in the future. The respondents found that these kinds of consultations and the presentations by guest

62 lecturers gave them the self-confidence to manage with their release and for becoming competitive in the labour.

The inmates also received information about who to approach if there would be problems in finding a domicile. A very important aspect was considered to be the understanding attitude of the lecturers towards the inmates by treating them as human beings and not as inmates. The course was rated positively by the inmates and they believed that everyone scheduled to be released from prison should complete the Programme. The respondents could not find anything negative about the course. Among the positive results was also the fact that the co-operation with the different institutions led to a change in their attitudes towards the prison and its inmates.

The Programme leader believed that the Programme’s general goal was achieved and the course was a success, thus inspiring further thoughts about, for example, engaging the inmate as quickly as possible after their incarceration. The first part of the program should focus on motivating the participants to change their behaviour and later focus on the skills for helping the participants to cope in freedom.

Leaving Prison

Release from the prison after completing a sentence must be carefully planned and prepared for. UNODC suggests pre-release preparation for resettlement in the society should begin one to two months before the actual release and continue after release for a certain period of time (depending on the individual case). During the pre- release period, the prisoner should follow a certain “programme of assistance to prepare for release to ensure that the social, psychological and medical support needs of the offender are met and will continue uninterrupted after prison “(UNODC 2007:47). Families should be involved in any reintegration programme.

Another approach is the establishment of transit houses/open prisons or half-way houses for women and their children who are released from detention: “These transit houses should be kept distinct from safe houses for victims of violence” (Townhead 2006:5). Institutions should help to built-up relations with the families and re-establish contacts with society and the world outside in general. Also, they should protect the recently released women from returned to their “old,” destructive circumstances or associated communities, including violent men, unemployment or homelessness. Here, the prison regime should cooperate with NGOs, social welfare institutions and social services in order to minimise the obstacles and their intensity encountered in the post-release reintegration of women.

5.2.6 Anger management

This Programme is imported from Finland and has been implemented in male and juvenile prisons in Estonia since 2001. At the beginning it was implemented in Harku Prison as well; however it was interrupted after some years when the trainers left. Since 2008 it is being re- implemented in this prison.

Anger management is targeted towards inmates who display tendencies towards impulsive and aggressive behaviours. The goal of the Programme is to improve their knowledge on what happens to them when they become angry, to explain to them why anger management tools are useful, and to give the participants a chance to manage their anger through role-play. In addition, it is also important to get experience with group work and to direct the participants to monitor and analyse their own behaviour, as well as to create and increase their interest in self- development.

The main topics of the sessions (in the progressing order of difficulty and time):

• Recognising situations that cause anger;

63 • Managing one’s body language; • Soothing thoughts; • Relaxation; • Pragmatic, assertive style of interaction; • Coping with criticism and insults; • Coping with peer pressure; • Identifying efforts to anger oneself; • Avoiding resignation, self-motivation.

Anger management is a short cognitive-behavioural course where the participants work on their thinking and behaviour through: lectures; watching sample situations; playing role-play games; conducting discussions; and doing their homework. The course consists of nine meetings, each session lasting for a maximum of two hours. For a less successful group, one topic may have to be discussed over two sessions, which doubles the length of the course.

It is important to show the participants that it is possible to avoid stereotype-based thinking and behaviours. In presenting real life situations, the most suitable moment is to implement new skills and knowledge through training. The inmates get more opportunities for self-expression, including through role-playing.

Feedback

The studies in male prisons have revealed that participants have been active and motivated to take part in anger management. As feedback, the participants have mostly reported that the group offered a friendly and trusting environment, which fosters the participant’s openness and opportunity for self-analyses. However it has also been reported that the course is too short, and could be longer or go deeper into covering the topic within the same group. Many claim to have used the knowledge and skills gained from the course in real life, including in quarrels and during conflicts, which they learned to prevent. The participants have reported positively about their experience, finding valuable abilities in themselves and learning how to better connect with other people.

It is well advised to design the programmes based on local needs and by local specialists. Programmes that are already known from other countries/institutions as well functioning could be adjusted according to the appropriate requirements and implemented.

Lithuania: In 1978 Panevezys Vocational Training Scholl No. 5 started training qualified dress- makers for their main enterprise, i.e. Panevezys Correction House (a penal institution for women). In 1998 the school was made into Panevevezys Vocational Training Centre Branch Office that could offer more opportunities for vocational training. Qualifications can be acquired to become a dress-maker, hairdresser and cook.

In 1978 a general education school with the staff of 12 experienced teachers was opened in the female prison. The inmates can receive primary, secondary and high school education, and can also enrol in the non-formal educational courses in English, German or Lithuanian languages, computer, and healthy lifestyle and art crafts.

The Training Centre at Panevezys Labour Market is implementing the following educational programs:

• Basics of computing • Needlework • Planting specialists • Florists

64 • Dress-makers • Environmental managers • Cane weawers.

Different Psychological Programs are available such as Psychological Adaptation Programs:

1. Anxiety and stress release, management of negative emotions; 2. Emotional support; 3. Getting to know oneself (making use of inner resources and reinforcement of one’s self-assurance).

Reintegration Programs:

1. Motivation of inmates to be released for professional activities; 2. Psychological interventions and probationary program.

Reform Programs:

1. Non-adaptive behaviour program; 2. Possibilities for use of inner resources and reinforcement of one’s capabilities.

5.3 VINN (WINNING)35 a good practice in social rehabilitation from Norway

VINN is a flexible and focused support-group program with an array of topics specially adopted according to women's needs.

The primary objective of the program is to build women's ability to make wiser choices that will lead to a better life e.g. without substance- or alcohol- abuse and without criminal activity and violence. Another objective is to increase the women's awareness about the interrelations between drug abuse/addiction, violence and crime.

The purpose: Women can overcome their alcohol- or drug addictions, and tap into alternatives lifestyles to crime. They can learn to develop a better relationship with their children, learn about raising children, and become able to create boundaries that keep violent partners out of their lives.

The theoretical background: The content of VINN reflects the basic humanistic approach to psychology, implying that people do have the ability to change. Pedagogically, the program based on the principles of Motivational Interviewing (Miller & Rollnick 2002) and the theory of the going through different stages in a process of change, originally developed by Prochaska, DiClemente and Norcross (1992). These theories correspond to a model that describes how motional change is possible and how the process of change should be supported by a facilitator. The VINN program has been developed by the Correctional Service of Norway Staff Academy by the Senior Advisor/Assistant Director Torunn Højdahl. A special Handbook/Manual for facilitators/group leaders and an Exercise Booklet for participants have been published and are used in the course of the program.

The target group of VINN: The program can be used in the correctional service, in probation, in centres for battered women and detox-institutions. VINN may suit women kept or serving

35 This chapter is based on various documents including: The Handbook/Manual for facilitators/group leaders, the Evaluation report, personal communication with Torunn Højdahl 2008 and reading of some literature on Cognitive Behavioral Therapy.

65 sentences in colonies/prisons, who are HIV-infected, abuse alcohol, medicines or drugs have a criminal lifestyle or have been battered.

The role of the facilitator/group leader: Facilitators work with a view to enabling solutions. Their goal is to elicit and support natural processes of change and also to explore ambivalence. It is important to explore women's personal resources and the strong character traits that women can use to overcome their own problems.

Different topics that cover several aspects of women’s lives can be chosen:

• Identity and self-esteem • Openness and communication • Change and choice • Substance abuse and dependency • Grief and loss • Boundaries in relationships • Anger • Violence • Children • Network and relationship

The programme is built on group sessions that take place two to three times a week with each session lasting two 2 hours. It is recommended that the program lasts for a period of five to twelve weeks. The VINN program has so far been used in several penitentiaries in Norway, some prisons in Sweden, and in one colony in Russia.

Evaluation: The VINN program was evaluated in 2007 by Dr. psychol. Per Kristian Granheim, on the basis of a questionnaire completed by participants from Swedish and Norwegian prisons, as well as from the Probation service of Akershus in Norway. The participants have in general a high score in regards to all of the topics of VINN, which indicates that they have benefited greatly from the program.

Conclusion: "Processes of change take time and support group do not solve all problems but it can give opportunities for reflection and learning, thus initiating a process of change leading to an improved quality of life" (Torunn Højdahl 2008).

5.4 NGOs’ involvement

Non-governmental organisations can play a central role in all national prison systems, especially when it comes to social-rehabilitation and pre-release training, education and vocational programmes. In many countries in the Northern Dimension area, NGOs have developed close relationships to the prison authorities in order to provide services which the national prison regime may not be able to offer in an appropriate extent. In the following section, the report will give some examples from the region concerning NGOs’ involvement in the social rehabilitation of prisoners before and after release.

5.4.1 In practice within the ND area

Estonian NGO Tallinna Hoolekande Keskus: This NGO provides various forms of support for people who experience difficulty in managing their lives after they have been released from prison and/or are homeless. People are expected to come if they are in need of:

• ID card • Residence or working permit • Help in searching for job • Help in applying for pension • Psychological counselling • Social skills training group for people released from prison • Shower • Second-hand clothes.

This rehabilitation centre has a day-care and an accommodation centre. A homeless night- shelter which has 30 beds and separate sections for men and woman is open every day from 21.00 - 09.00 hrs.

In the day- care centre, the following services are offered free of charge:

• Social counselling • Psychological counselling • Social skills training groups for people released from prison • Food • Shower • Razors, soap, used clothes, etc • Books, newspapers, magazines, TV • Internet & e-mail access • Sewing machine.

Ex-prisoners who have no permanent living quarters have the possibility to enjoy accommodation in the rehabilitation centre under the terms of an agreement.

France: GENEPI National student organisation for teaching prisoners (Groupement Étudiant National d’Enseignement aux Personnes Incarcérées) is a French student organisation which bases its work on 1300 volunteers who will work inside prisons in France. GENEPI works together with other organisations such as the Red Cross, Penal Reform International and Observatoire International des Prisons (OIP). The idea behind GENEPI is that students voluntarily joint the NGO and support the imprisoned fellow citizens, and in that way execute their civic duty. The volunteer organisation organises and participates in prison rehabilitation programmes, giving educational support to prisoners and promoting cultural activities in prison. The group itself cooperates with other grassroots organisations.

The NGO splits its work into activities inside and outside the prison. Inside, they provide general school education as mathematics, physics, French and other languages. Furthermore, they provide high-level classes where inmates can study law, philosophy and economics. The idea behind this is to spark interest among inmates in certain subject areas or support their interest in particular fields. Of course the other intention is to make general school education available to those who do not have a school degree or have not received basic education (due to e.g. early school drop out). Inmates are preparing for studying for a degree, and thereby, to improve their chances of employment after their release. This project also aims to increase literacy in prison and in the French society in general. Thereby, the student organisation offers mainly language

67 classes in French for French-born prisoners, but also French as a second language (francais langue etrangére).

Students organise and conduct socio-cultural events and activities with and for inmates such as theatre, dancing classes, arts and crafts classes. There is also a possibility to read the newspapers and other press together and to discuss current political and social issues.

All activities aim to support the social rehabilitation and reintegration of prisoners into society after their release.

Outside, GENEPI organises information- and awareness-raising events for the general public. Thereby, the NGO works to prevent and reverse biases and prejudices existing in the general public about prison inmates. GENEPI organise events in schools for students and undergraduates, in the general public with exhibitions, conferences, concerts and workshops.

Russia: The UVENTA foundation is working on the same level with a group of students offering philosophy and psychology classes to prisoners.

Russia: In camp 14 in the republic of Mordovia, the prison regime works on the basis of an adaptation system developed in Norway, and tested in the settlements of the rehabilitation centre. All prisoners spend their first three months of their sentence in a so-called adaptation group, and six months before the release they gather in a pre-release group preparing for release.

Sweden/Russia: The Swedish Development Agency SIDA supports a project that is called: Development of the organisation “CRIMINALS RETURN INTO SOCIETY” in St Petersburg region.36 The project started in 2006 and will continue until 2009. SIDA will support a project regarding the start-up of two organisational branches of the NGO “Criminals Return Into Society” (C.R.I.S. in Leningrad Region). The branches will be of assistance to discharged prisoners during their first period of freedom. The support will consist of various measures for the target group, such as competence development and information activities directed towards prisons, authorities and schools.

C.R.I.S. was formed in 1997. The association consists of more than 3,900 (January 2003) former criminals. Most of them had been addicted to drugs or alcohol and are now living drug- free and law-abiding lives. There are also about 900 supporting members from all classes of society, including the Royal King of Sweden. They try to be of assistance to discharged prisoners during their first period of freedom, attempting to make life meaningful for them. The idea is that people who have experienced addiction, crime and correctional treatment, and now live a life free from drugs from and without criminal activities, constitute the backbone of the association and support those who have just been released from prison and need positive reinforcement. Before their date of release, prisoners establish contacts with new acquaintances that they came to know during their prison term.

In order to give a prisoner an honest alternative to a life of crime, C.R.I.S. contacts inmates while still incarcerated. The contacts are intensified during the period just upon release. At the date of release, a number of C.R.I.S. members meet the prisoner outside. An important feature of C.R.I.S. is that its work pools supervisors. Older members of the association are meant to serve as an integrating link between new members and society and its authorities on the other hand. The idea is that the recently released member should be able to get in touch with his/her “godfather” or “godmother” by phone or personally, in order to get direct help and support in difficult situations. The godfather or godmother has experienced the same practical everyday

36 Decision no: 2006-001984, Swedish part: RIKSKRIS, SIDA contribution: SEK 3 000 000.

68 problems that are difficult for an outsider to understand. The godfather and the godmother are reachable 24 hours a day and are equipped with a mobile phone that may also be issued to the released member as well. The godfather and godmother activities are developed in collaboration with probation officers, in order for godfathers and godmothers to receive future status as layman probation officers (http://www.kris.a.se/akutinfo.htm).

Latvia: The State Probation Service was established in October 2003. It is a national institution within the Ministry of Justice with a mission “to care about public safety through rehabilitation of offenders and supervision of offenders in society”. The national service is cooperating with correctional institutions in preparing inmates for release into society, provides assistance to recently released offenders, develops programmes for the correction of social behaviour of offenders, organises meditation between offenders and victims, and organises community work service. The service has 28 regional offices all across the country. The service aims to overcome the lack of social programmes for offenders before and after release, the lack of half way housing and the fight of social problems leading to imprisonment or coming up right after release as poverty, unemployment and alcohol addiction.

The activities are based on the initiative of the European Commission “Equal project,” offering new solutions to promote the employment of ex-prisoners” during in the years 2005- 2007. Its main task is to develop a framework for rehabilitation, education and employment of prisoners and ex-prisoner system. The outcome of the project in Latvia is the establishment of centres for social rehabilitation as a component of the prison administration. They have established the prison’s social rehabilitation centres (PSRC) in four prisons, one of them at Ilguciema prison for women. Four centres for social rehabilitation for ex-prisoners (SRC) have set up a plan for general and vocational training and have established a special unit for the coordination of the work practices. Project activities have included establishing of places for work, improving the general and vocational education programmes in prisons, and developing and piloting programmes for social rehabilitation. The project has published a handbook for officers in prisons, and has also developed and disseminated information material for ex- prisoners, informing them about the access the social rehabilitation programme’s services in the SRC’s. An additional step was to involve and inform potential employers about the possibilities for cooperation and the employment of prisoners. Based on the project, the state probation service compiled recommendations in order to improve the employment and vocational training situation for prisoners in Latvia.37

Lithuania: In 1997 alcoholics Anonymous group was established in Panevezys Correction House for women. In 2002 another group, Drug Addicts Anonymous group was created. Their activities are based on the 12-Steps Program. Two centers for dependence diseases treatment and psychological rehabilitation are functioning in the penal institution. Around 30 inmates are undergoing treatment for dependencies according to the Minnesota Program.

Poland: The Polish NGO MONAR was already established in 1978 and is working with social re-adaptation programs. Since 1993 the NGO is organising a regular assistance programme for e.g. ex-prisoners, providing half-way housing and first shelter in residential housing, and thereby actively offers help and assistance to people released from custody.

In general, giving educational and vocational programmes to prisoners with longer sentences only is counterproductive. Shorter sentences, alternative measures and education and rehabilitation programmes are adequate measures to fight criminality, poverty, marginalisation and health risks. Those should also be available to prisoners with short sentences, and mainly

37 For more information on the European Commission initiative Equal – new approaches to the resettlement of (Ex)offenders see http://ec.europe.eu/employment_social/equal/.

69 to women who are released after a short time (as they accordingly need specially tailored guidance).

Norway: Prison Visitor is a non-governmental association. It offers services to all prisons in Norway, including within female prisons. It has functioned for several years and is well known by the inmates who can enjoy their services on a voluntary basis.

The Norwegian Red Cross established in 2005 a “Net-work co-operation” with prisons in Norway. The female prison Bredtveit has since the beginning of 2006 enjoyed this service. Voluntary members from the Red Cross are in contact with individual prisoners as long as they are serving their sentences in prisons and remain in touch with them for up to two years after they have been released. The purpose is to develop a social network without drugs and criminality. The “Net-work co-operation” has no other function than to offer a social framework in which a pleasant time can be had together with the prisoner. The Red Cross-member can meet the prisoner either in the prison or during a leave. Red Cross can also invite for a trip or organise happenings. The “Net-work co-operation” organised in 2006 and 2007 a one-week trip to the seaside of Norway. The “Net-work co-operation” is looked upon very positively and is well appreciated by the inmates and the prison authorities. It will be developed into a national project.

The Crisis Centre in Oslo is a non-governmental organisation that helps and supports women who have been victims of violence and abuse or have suffered from other bad experiences. Similar Centres are located in many different places in Norway. Bredtveidt prison and the Correctional Service Region East have established co-operation with the Crisis Centre in Oslo. The Centre has created dialogue-groups for women and can also provide individual conversations with female prisoners, either in the prison or in the Crisis Centre’s own facilities outside the prison.

5.5 Alternative measures to prisons for non-violent offences

Alternative sentencing is often seen as being more cost-effective than incarceration for non- violent offenders. Instead of incarceration, it could be more successful to provide these offenders with community-based programmes, where the prisoners themselves support the greater society/community/public service. Thereby, a sentenced woman could maintain a job or be in job-training, which could give her new skills to making-a- living after her sentence is complete, for benefit for the society. Charon Schwartz (2001) suggests community services as being very beneficial to the social rehabilitation of female non-violent offenders: “Why not allow them to spend time to soothing the cries of a baby born addicted to drugs, or let them read stories to children in hospitals dying of cancer, let them feed the hungry or homeless […]” (Schwartz 2001). A more holistic approach, as Schwartz calls it, would demonstrate to women the ways in which they can regain self-respect and rebuild their self-esteem.

In cases where female offenders do not pose a risk to the public, their rehabilitation needs, parental status and the harmful impact of imprisonment should be taken into account. The Tokyo Rules, as pointed out by the UNODC (2007:68) give some guidelines for alternative sentencing for women:

• Verbal sanctions • Conditional discharge • Status penalties • Economic sanctions, monetary penalties • Confiscation or expropriation order • Restitution to the victim or compensation order

70 • Suspend or differed sentence • Probation, judicial supervision • Community service order • Referral to an attendance center • House-arrest • Combinations of measures listed above

5.5.1 In practice within the ND area

Russia: A sentence can be postponed, reduced or cancelled for pregnant women or women having a child who is younger than 14 years old, with the exception of those who have a sentence of more than five years (Criminal code of Russian Federation, Article 82).

Finland: In Finland the view on prisoners has changed over the last years. The Finnish state and the society were questioning the sense of punishment and the actual impact that imprisonment had on society in general and the individual in particular. The debate generated the idea of opting for imprisonment less and instead opting for more rehabilitation programmes, open prisons, electronic bracelets and trial period as alternative measures. More than one-third of Finnish prisoners serve sentences of less than one year and less than 8% of the penalties are sentences for more than ten years, according to the prisoners’ organization Ban Public (http://www.prison.eu.org/).

Canada: Canada developed the so-called private family visit programs during the late 1980s. Canadian Programs for private family visiting for successful social rehabilitation are currently representing the best ways of preserving social, family and conjugal ties between incarcerated individuals and their intimates (http://champpenal.revues.org/).

Prisoners sentenced to two years or more should have the possibility of rehabilitation for social life. To do so, a number of programmes have been set up and developed to meet the potential social and psychological needs of imprisoned individuals. In addition to these special programmes, the Canadian custodial institutions give the possibility of lengthy private family visiting (PFV). The intention of this programme is to maintain the social family and conjugal ties between the prisoners and families and friends and at the same time: “to reduce the punishment inflicted on families of offenders” (http://champpenal.revues.org/). As stated as objectives of its mission, the correctional service Canada works to “assisting the rehabilitation of offenders and their reintegration into the community” (http://champpenal.revues.org/). Prolonged visits of members of the community and from outside the prison should preserve the social and family unit, inasmuch as possible, as well as to reinforce the offender’s role and status as citizen and parent.” These are to be seen as stabilizing factors of the later release and the successful reintegration into society. The report quotes that “in addition, statistics show that if an inmate’s family is still intact and ready to accept the inmate upon release, the inmate’s chance of leading an honest life are greatly enhanced.”

Possible visitors are not only family members but can also be close friends and relatives. The private family visitation programme is open to all inmates. Some exceptions might occur in cases where there is an acute threat to the family or certain members of the family by the prisoner, or because the inmate has access to other programmes. Private family visits last 72 hours at most and may occur every two months. They take place in a special area, separated from the rest of the prison where the families have the possibility to stay on their own, have cooking and sleeping facilities, structures in furnished apartments, also providing some space outside, like a courtyard. During the visit, the staff must maintain contact to the prisoner; food and personal belongings are checked before the visitors are entering the prison. These checks are to be done prior the visits to keep the privacy during the stay of the family members. Champ

71 pénal concludes about the long term private stays: “one must never lose sight of the fact that the offender will return to the community some day and that everything possible must be done to achieve the best possible […] rehabilitation, but also that mutual support between incarcerated persons and their intimates is an indispensable factor both for survival in detention and for enabling those outside to cope with that absence” (http://champpenal.revues.org/).

Chapter 6

RECOMMENDATIONS

Photo by Amy Allock

Based on the findings presented in this Thematic Report on women’s health in prison, the NDPHS Expert Group on Prison Health puts forward the following set of project-based recommendations:

1. Social-economic background screening: It is recommended that social background screenings of every woman entering the prison for the first time are consistently and thoroughly conducted. This includes setting up a standardized questionnaire/template to collect useful data regarding the women’s social and economic backgrounds, also covering their health status. One purpose of such information collection would be to facilitate a comparative study on the social and economic backgrounds of women in prison, and to sufficiently meet their particular health care needs.

2. Gender Equality: As this Thematic Report emphasises the importance of gender equality and its accompanying principles, the Expert Group recommends that a project be undertaken which will analyse the implementation of basic human rights, specifically in relation to social rights, economic rights and cultural rights for both genders, also incorporating the right to access to health care services. The project should cover the implementation of these basic rights in prisons, taking into account that detained women are still discriminated against in social, economic and cultural terms. As stated earlier, discriminatory attitudes and behaviors, including stereotyping, is very present with prison environment. Such biases have to be overcome.

73 3. Reform in Prison Health: The Expert Group deems it important to carry out a project that will analyse health-related prison reforms underway in prison systems found in different countries of the ND area. Such a project should provide an overview of the various types of ongoing and planned projects in any of the ND countries, as well as describe and define the different type of reform steps/measures. Furthermore, a comparative study could analyse quantitative and qualitative differences among health care services provided - if any - within the ND countries, depending on what actors are responsible for overseeing prison health services. Such a project will also raise awareness of national decision-makers (e.g. Ministry of Justice, Prison Administration) on the need to address the vulnerability of female prisoners to different disease including HIV/AIDS, and to provide the comprehensive package of services within prison settings in a gender-sensitive manner, free of stigma and discrimination. In here then we can jointly work with HIV/AIDS EG

4. Living conditions: The Expert Groups sees great potential for a project that will serve as a study on the living conditions of female prisoners in general and the organisation of health care services for imprisoned women in particular. Again, this study should be comparative, using qualitative as well as quantitative, and primary and secondary data (according to what is available).

5. Birth: A fifth recommendation includes the idea to undertake a project on birth companions, based on the British good practice model. In this way, it is recommended to transfer this project idea to the ND area and to initiate a “pilot project” which sets up the system of birth companionship in female prisons in with different countries of the ND area, possibly in cooperation with the relevant British NGO.

6. Children: In terms of female prisoners accompanied by children, another recommendation for a project could include taking a closer look into the influences on and consequences for the child’s development. Circumstances for analytical consideration could be: :

a. if the child accompanies the mother in prison for the first years of her sentence and b. if the child is outside the prison but regularly visits the mother in prison.

7. Data collection: A further recommendation stems from some of the comments presented in the introductory chapter concerning a lack of data on women in prison. It is therefore recommended that a quantitative study across the Northern Dimension Area and beyond be conducted, in order to collect quantitative data on women’s living conditions and their health status in prisons. A standardized questionnaire should be developed and issued to each female prison in the area, also taking into account pre-trial as well as closed prisons. In developing a standardized questionnaire, there should be common understanding of which indicators and parameters should be measured in order to monitor and asses the performance of a given prison and the national health system.

8. Education and social rehabilitation: the Expert Group suggests that a project which examines different models of peer education taking place in countries such as France and Estonia be initiated. In addition, we recommend that a project be developed to establish and/or strengthen the links between prison authorities, including medical health services, the community health services and various NGOs. Cooperation on issues such as HIV and TB prevention and care, drug-rehabilitation, pre-release training and education, and post-release activities would be of particular importance.

9. Post-release: A final recommendation is to establish a post-release study/project that mainly serves as a follow-up on women’s rehabilitation after their release from prison, and especially the provision of health care and treatment initiated while in prison. This should also include monitoring the measures that were taken to successfully reintegrate women into society, even if they were in prison for only a short period of time. Post- release studies could also cover women´s housing possibilities following their release, focusing espeically on the provision of half-way houses and other possibilities for accomodation after release.

10. Capacity building: The Expert Group emphasizes the importance in provision of gender-sensitive services to female prisoners. EG suggests developing and implementing projects related to training of service providers from governmental and civil society organizations in provision of such services. Those projects can include skills needs assessments among existing and potential service providers, development of gender sensitive training materials and manuals, locally adapted to specific social and cultural contexts. Training of peer educators on different issues including ones related to HIV and STI prevention, early detection and treatment measures. Promotion of national and international training and seminars on female prisoners to share experiences and examples of evidence-based practice.

75 Appendix I List of references

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Appendix II Questionnaire

NDPHS Expert Group on Prison Health Thematic Report 2007: Women’s Health in Prison

+ + + Questionnaire + + +

In general, people who are in prison need a high level of health and social care. Women are a minority in prison but they are one of the most vulnerable groups when it comes to health issues and health care settings. As the majority of the prison population consists of male detainees, women’s special needs are often neglected. However, over the past years, the number of female offenders has risen at a greater rate than of their male counterparts in a number of countries in Europe.

As decided at PH EG 3rd Expert Group meeting in Paris in June 2007 and further discussed at the 4th PH EG meeting in Copenhagen in October 2007, the PH EG will publish a Thematic Report38 on women’s health in prison.

The PH EG Thematic Report 2007 concerns how prison health for women is organized and how health care in prison is adequately adjusted to women’s needs. In finding good practice examples from the ND region, the report focuses on two main issues, with additional one sub- issue each:

1. Women accompanied by children and pregnant women a. HIV/AIDS infected women

2. Post release reintegration and social rehabilitation a. The role of NGO’s during imprisonment and after release of women

Since October 2007, an External Expert is working on the Thematic Report. Following the given PH EG Terms of Reference for Thematic Report, an Editorial Group was also established, which held its first meeting during the end of November.

The PH EG’s Thematic Report topic is also of relevance to a planned conference on women’s health in prisons, organized and hosted by the WHO Europe “Health in Prison Project” (HIPP) in 2008 and a planned publication on women’s health in prison.

In order to collect current data on the health status of women in prison, in the ND area, the Editorial Group of the EG Prison Health needs the help of the NDPHS member countries and its representatives. We would like to kindly ask you to provide answers to the following questions listed in the questionnaire below. The answers will be used to compile the first chapter of the Thematic Report, giving a geographical overview on the location of different categories of women’s prison and describing the general health situation/ issues of imprisoned women in the ND area and NDPHS member states.

38 Following the NDPHS and EG PH Terms of Reference, the production of Thematic Reports builds one partnership approach supporting coordinated and collaborative efforts to further prison reforms, develop relevant national policies and to promote networking and partnership-building among all relevant stakeholders in the field of interest.

86 The first table asked for information on the country and the contact details of the person providing the information to the PH EG. In the second table, we would like to ask you to give your answers numerically, in percentages or short notes in the “answer” column. If you have remarks or any additional information to the questions, please type them in the column “additions”. If you cannot give an answer to a question, please leave the field blank. Please feel free to choose a separate document or to create additional tables, if necessary. Indicate the question to your answer by marking them with the number of the question. Please attach additional documents to the questionnaire in the same file.

A Contact information Country

Last Name: First Name:

Position/ Title: E-mail:

Phone: Fax:

No. Question Answer Remarks 1 Number of female prisons of any type in the country, (or divided by categories e.g. pre-trial, short- term, long-term etc.) 2 Names and locations of women’s prison of any type in the country (or divided by categories e.g. pre-trial, short-term, long-term etc.) 3 Distance in kilometres between the prison or any other establishments and the next hospital/prison hospital 4 Total number of imprisoned women in the country in any type of prison (or divided by categories e.g. pre-trial, short- term, long-term etc.) 5a How is the medical service in female prisons organized (please specify for the different categories of establishments, if possible) 5b What kind of staff is available in the women’s prison? 5c How often is it possible to see A doctor: A nurse: Other medical staff (please specify): 6 Latest estimated number of

87 women in prison infected with Tuberculosis 7a Latest estimated number of women in prison infected with HIV/AIDS 7b Is there a possibility for female prisoners to receive antiretroviral treatment? 8 Is substitution treatment available for all female prisoners upon request? 9a Latest number of cases of self- harm of women reported for any kind of prison 9b Latest number of cases of suicide of women reported for any kind of prison

10 Latest number of imprisoned women undergoing psychological intervention in any kind of prison 11a Is there a possibility for women to be with their children during imprisonment? 11b If yes, until what age is the child allowed being together with the mother in prison? 11c If yes, how is childcare in prison organised in your country (please specify by different categories of imprisonment, if possible)

Please send your compiled answers, saved within this file by electronic mail to: Ms Maxi Nachtigall (External Expert, Expert Group on Prison Health, Thematic Report 2007): [email protected]

Please return the completed questionnaire at your earliest convenience but not later than 21 December 2007. The information provided and sources referred to will be cited according to general regulations.

Appendix III Index of Tables and Maps

Table 1: Female population in prison – total numbers/ percentage of total prison population by 1 September 2006, if not indicated differently, also including pre-trial detainees.

Map 1: Number of women’s prisons and prisons with women units in countries in the ND region

Table 2: Number of MBUs in countries in the ND region (Townhead 2006:48, NDPHS questionnaire)

Table 3: Maximum number of years that children can stay with their mothers in prison (Duenckel et.al 2005).

Table 4: Percentage of children who are staying with their grandparents while their mothers are in prison (Duenckel et.al 2005).

Table5: Percentage of children who stay in children’s homes. (Duenckel et.al 2005).