In its decision for Estelle v Gamble (1976), the U.S. Supreme Court identified deliberate indifference to the needs of incarcerated persons as a violation of the eighth amendment to the Constitution.1 Thus, health care effectively became a constitutional right for people in prisons and jails in the United States.
Although Estelle v Gamble was an essential start for enabling individuals in correctional facilities to receive health services, stigma against justice-involved populations continues to compromise their well-being. One key way in which stigma becomes manifest is in the widespread usage of disrespectful and dehumanizing language in the health care field—this includes words such as “felon,” “convict,” and “offender.” We posit that maintaining these labels could indirectly impair the health of individuals who have been incarcerated, both inside and outside of the correctional setting, by entrenching the stigma that these individuals already face. Physician leaders in academic medicine need to inspect their vocabulary as they prepare the next generation of medical trainees to assume future leadership in medicine.
Scope of Criminal Justice Involvement in the United States
The sheer magnitude of criminal justice involvement in the United States and its impact on health outcomes (see below) suggest that physicians and medical trainees are likely to encounter incarcerated persons or their immediate family members on a regular basis as they provide care. On any given day, 6.6 million American adults are under the supervision of the criminal justice system, with 2.2 million in jails and prisons and 4.4 million under parole or probation supervision in communities.2 Moreover, 10.6 million persons are newly admitted into jails and prisons annually.3 Young African American men are disproportionately incarcerated in the United States.4 Nevertheless, other segments of the population are catching up; women, for example, represent a growing segment of the criminal justice system.5 With the addition of those on parole or probation, 1 in 38 Americans are under criminal justice supervision on any given day,2 and 5 million children in the United States have a parent who is incarcerated.6
In response to these and other such concerning statistics, the Association of American Medical Colleges convened a panel at their 2017 annual meeting focused on correctional health entitled “Social Justice Behind and Beyond the Bars: Criminal Justice Health and Academic Medicine,” which featured a video of interviews with incarcerated and formerly incarcerated persons that powerfully described the impact of stigma as one of many barriers they face when trying to access health care.7 This panel and video are emblematic of a growing awareness of the need to address the health of incarcerated and formerly incarcerated persons.
Health Status of Justice-Involved Persons
Correctional populations as a whole shoulder a disproportionate burden of chronic disease.8 They are also aging.9 Health issues and trauma-related experiences can exacerbate the feelings of isolation, loneliness, and harsh austerity of correctional settings. As prison populations age, complex health and social problems in these settings become normative and necessitate coordinated, dignified, and multidisciplinary care.10,11
Prisons and jails have become the de facto medical homes of persons with severe mental illnesses, substance use disorders, and chronic infections as a result of injection drug use.12 Approximately one-half of persons in prisons and two-thirds in jails have experienced serious psychological distress or have a history of mental health problems.13 Although quality epidemiological data remain scarce,14 it is widely believed that individuals with justice involvement experience inequalities in access to quality health care outside of correctional facilities, as well as wide variations in access to quality care inside of correctional facilities.15 Individuals returning home from prisons in one state had a mortality rate 12.7 times higher than that of the general population in the first two weeks after release, mostly due to drug overdose, which may be prevented if people are prescribed medication-assisted treatment while incarcerated and when they leave jails and prisons.16,17 People released from custody are also at increased risk of suicide, nonsuicidal self-harm, and other forms of preventable injury.16–19
These statistics are reason enough to raise the alarm among health care providers and criminal justice researchers about the need to conceptualize better ways to administer health care, both inside and outside of jails and prisons, to persons who have experienced incarceration. Persons who have contact with the justice systems have led calls for academic health centers to take a stronger leadership role in mitigating the health impact of mass incarceration in the United States.20,21 Using person-first language for individuals currently and formerly incarcerated is one critical action and would be symbolic of other efforts to ensure dignity and respect when serving justice-involved patients and their families who live on the margins of society. Research in criminal justice settings has documented poor rapport building, a lack of trust, and poor communication as causes of poor health outcomes among individuals who have spent time in prisons or jails.20 Further, individuals with a history of justice involvement are not likely to seek health care in the community if they feel judged or disrespected.22 Unfortunately, many health care providers and criminal justice researchers do not yet use language for individuals who have experienced incarceration that helps to decrease stigma and discrimination.
Employing Destigmatizing and Humanizing Language
Person-first language for justice-involved people has been promoted in many spheres, including justice organizations, but to date, it has not been fully embraced by medical providers or criminal justice researchers.23 Individuals in jails and prisons are vulnerable to health inequalities within the prison system itself, in part because of providers’ attitudes and lack of knowledge about how to respond to and care for such patients.24 As the hepatitis C epidemic has demonstrated, budgets for health care fall short of covering the carceral population’s health needs.25 Furthermore, there is a long history of research-related abuse toward incarcerated individuals due to stigmatizing views of this population.26,27 However, if we as medical professionals and criminal justice researchers are to gain the trust needed to make an impact, any effort to mitigate the present state of affairs must be carried out with respect at its foundation. We believe an important first step that will demonstrate this respect is to use destigmatizing and humanizing terms for this population to help reduce the stigma that they face. To this end, in Table 1 we provide a list of commonly used pejorative terms for individuals who have experienced incarceration and suggest replacements.
The language that clinicians in academic medicine use to describe patients ultimately influences their interactions with those patients.28–30 It also matters in interactions with the next generation of providers—medical trainees—as language can influence how providers interact with patients. To address a paucity of exposure to the care of individuals in correctional systems in both undergraduate and graduate medical education31 and the need to recruit more clinicians to serve in correctional care settings, many have called for increased focus on incarceration and health in the training of future health care professionals.21,31 As these curricular initiatives expand, infusing opportunities for trainees to reflect on and practice applying person-first language for this population could complement the development of correctional care competencies. Additionally, an initiative similar to the efforts that have been undertaken to characterize—and subsequently address—the attributes that medical trainees associate with patients with disabilities32 could be implemented for justice-involved populations. Such an initiative would also be an opportunity for reciprocal learning experiences, in which students could glean knowledge and narratives from justice-involved individuals at the community level.
Despite the fact that calls to use person-first language have been issued by authoritative organizations addressing the needs of individuals with mental illness,33 individuals with disabilities,34 and individuals who are obese,35 the health care profession and criminal justice researchers have not yet kept pace in our dialogue and publications. Nor have we made strides to issue our own calls for individuals who have experienced incarceration. In contrast, language used to describe people experiencing problems with substance use disorders has shifted in recent years from pejorative labels such as “junkie,” “dope fiend,” and “substance addiction” to more objective, respectful terms such as “people who inject drugs” and “substance use disorder.”
In a recent interview, Michael Botticelli, the former director of the Office of National Drug Control Policy under President Obama, stated: “Often when we call people things like ‘addict’ or ‘junkies,’ not only are they incredibly judgmental words, but they also kind of pigeonhole someone’s entire being to that one single characteristic.… These are issues, and these are words that have a dramatic impact on both clinical care and about how medical professionals see and treat people with addiction.”36 Using person-centered language aligns with the current editions of the Diagnostic and Statistical Manual of Mental Disorders and AMA Manual of Style.37–39
In both our professional and personal lives, we have firsthand experiences of witnessing the negative impact of using labels such as “convict,” “felon,” and “offender,” as well as the considerable barriers they can create for successful community reentry. For example, applications for housing and employment that inquire about criminal justice history often obscure an individual’s intrinsic skills and capabilities in favor of focusing on their criminal record. It may not be surprising, then, that individuals recently released from correctional facilities face challenges with housing and employment stability, effectively exacerbating the risk of recidivism and poor health outcomes, as housing and employment status are social determinants of health.40,41
Ultimately, we recognize that language is powerful, and that changing language is difficult. Many providers, persons who are incarcerated, and those leaving incarceration find it difficult to change the labels. Awareness is the key to continuing the journey that has been started by criminal justice organizations such as Just Leadership USA, the Fortune Society, and the Osbourne Association—all staunch advocates for person-first language. The field of academic medicine and criminal justice researchers should adopt these same ideals as a critical element of improving health, research, and advocacy. We need to start making a conscious effort to replace harmful labels with labels that do not convey judgment or bias in both clinical practice and research (see Table 1). One avenue for making progress on the latter is for the National Library of Medicine to support the use of less stigmatizing or pejorative language in Medical Subject Headings (MeSH) search terms, which currently use the heading “prisoners.” Given the widespread usage of MeSH terms in the clinical sciences, the potential reach of a simple modification to use a term for the setting (i.e., “prison”) rather than a term for the persons could be significant. To this end, we will be sending a copy of this Invited Commentary to the MeSH Suggestions portal to advocate for a change in MeSH vocabulary.
Promoting a just society for all calls for transformative justice for incarcerated individuals and their family members who have contact with the justice system. Providing opportunities to the segments of our society who have been most affected by the epidemic of incarceration will help to make their efforts to rebuild their lives possible. The challenge for the medical profession and criminal justice researchers is to start using person-first language for patients with a history of incarceration as part of a broader strategy to rectify historical injustices inherent to the correctional health care system. The academic medicine leaders of today need to set the pace so that those they teach can carry the torch forward.
“Any system that allows us to turn a blind-eye to hopelessness and despair, that’s not a justice system, that’s an injustice system … Justice is not only the absence of oppression; it’s the presence of opportunity.”42
—President Barack Obama
1. Estelle v Gamble, 429 US 97 (1976).
4. Alexander M. The New Jim Crow: Mass Incarceration in the Age of Colorblindness. Choice Rev Online. 2010;48:48–1766.
7. Association of American Medical Colleges. Social Justice Behind and Beyond the Bars: Criminal Justice Health and Academic Medicine. https://vimeo.com/238117191
. Accessed September 4, 2018.
8. Binswanger IA, Krueger PM, Steiner JF. Prevalence of chronic medical conditions among jail and prison inmates in the USA compared with the general population. J Epidemiol Community Health. 2009;63:912–919.
10. van Dooren K, Richards A, Lennox N, Kinner SA. Complex health-related needs among young, soon-to-be released prisoners. Health Justice. 2013;1:1.
11. Skarupski KA, Gross A, Schrack JA, Deal JA, Eber GB. The health of America’s aging prison population. Epidemiol Rev. 2018;40:157–165.
12. Spaulding AC, Drobeniuc A, Frew PM, et al. Jail, an unappreciated medical home: Assessing the feasibility of a strengths-based case management intervention to improve the care retention of HIV-infected persons once released from jail. PLoS One. 2018;13:e0191643.
14. Kinner SA, Young JT. Understanding and improving the health of people who experience incarceration: An overview and synthesis. Epidemiol Rev. 2018;40:4–11.
15. Rubenstein LS, Amon JJ, McLemore M, et al. HIV, prisoners, and human rights. Lancet. 2016;388:1202–1214.
16. Binswanger IA, Stern MF, Deyo RA, et al. Release from prison—A high risk of death for former inmates. N Engl J Med. 2007;356:157–165.
17. Spittal MJ, Forsyth S, Pirkis J, Alati R, Kinner SA. Suicide in adults released from prison in Queensland, Australia: A cohort study. J Epidemiol Community Health. 2014;68:993–998.
18. Borschmann R, Young JT, Moran PA, Spittal MJ, Kinner SA. Self-harm in the criminal justice system: A public health opportunity. Lancet Public Health. 2018;3:e10–e11.
19. Young JT, Heffernan E, Borschmann R, et al. Dual diagnosis of mental illness and substance use disorder and injury in adults recently released from prison: A prospective cohort study. Lancet Public Health. 2018;3:e237–e248.
20. Ferguson WJ, Cloud D, Spaulding AC, et al. A call to action: A blueprint for academic health sciences in the era of mass incarceration. J Health Care Poor Underserved. 2016;27(2A):5–17.
21. Trestman RL, Ferguson W, Dickert J. Behind bars: The compelling case for academic health centers partnering with correctional facilities. Acad Med. 2015;90:16–19.
22. Morse DS, Cerulli C, Bedell P, et al. Meeting health and psychological needs of women in drug treatment court. J Subst Abuse Treat. 2014;46:150–157.
23. Binswanger IA, Redmond N, Steiner JF, Hicks LS. Health disparities and the criminal justice system: An agenda for further research and action. J Urban Health. 2012;89:98–107.
24. Sue K. How to talk with patients about incarceration and health. AMA J Ethics. 2017;19:885–893.
25. Nguyen JT, Rich JD, Brockmann BW, Vohr F, Spaulding A, Montague BT. A budget impact analysis of newly available hepatitis C therapeutics and the financial burden on a state correctional system. J Urban Health. 2015;92:635–649.
26. Hornblum AM. Acres of Skin: Human Experiments at Holmesburg Prison. 1998.London, UK: Routledge.
27. Miller J. Medical apartheid: The dark history of medical experimentation on black Americans from colonial times to the present. Psychiatr Serv. 2007;58(10):1380–1381.
28. Cooper A, Kanumilli N, Hill J, et al. Language matters. Addressing the use of language in the care of people with diabetes: Position statement of the English Advisory Group [published online ahead of print June 11, 2018]. Diabet Med. doi:10.1111/dme.13705
29. Kraus ML, Isaacson JH, Kahn R, Mundt MP, Manwell LB. Medical education about the care of addicted incarcerated persons: A national survey of residency programs. Subst Abus. 2001;22:97–104.
30. Lloyd CE, Wilson A, Holt RIG, Whicher C, Kar P; The Language Matters Group. Language matters: A UK perspective [published online ahead of print August 13, 2018]. Diabet Med. doi:10.1111/dme.13801
31. Giftos J, Mitchell A, MacDonald R. Medicine and mass incarceration: Education and advocacy in the New York City jail system. AMA J Ethics. 2017;19:913–921.
32. Byron M, Cockshott Z, Brownett H, Ramkalawan T. What does “disability” mean for medical students? An exploration of the words medical students associate with the term “disability.” Med Educ. 2005;39:176–183.
33. Davidson L, Bellamy C, Guy K, Miller R. Peer support among persons with severe mental illnesses: A review of evidence and experience. World Psychiatry. 2012;11:123–128.
34. Feldman D, Gordon PA, White MJ, Weber C. The effects of people-first language and demographic variables on beliefs, attitudes, and behavioral intentions toward people with disabilities. J Appl Rehabil Couns. 2002;33:18–25.
35. Wittert GA, Huang KC, Heilbronn LK. Supporting the callout for people first language in obesity. Obes Res Clin Pract. 2015;9:309.
37. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 2013.5th ed. Washington, DC: American Psychiatric Association.
38. Goshin LS. Humane language for people in the criminal justice system. JAMA. 2017;318:2258–2259.
39. American Medical Association. AMA Manual of Style: A Guide for Authors and Editors. 2007.10th ed. New York, NY: Oxford University Press.
40. Freudenberg N. Jails, prisons, and the health of urban populations: A review of the impact of the correctional system on community health. J Urban Health. 2001;78:214–235.
41. Petersilia J. When Prisoners Come Home: Parole and Prisoner Reentry. 2003.New York, NY: Oxford University Press.