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Review of Indigenous offender health

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What do we know about the Indigenous offender population?

In June 2012, there were 29,381 prisoners in Australia, 93% of who were men [1]. Indigenous prisoners made up 27% of the total prisoner population (Table 1). Indigenous people were 15 times more likely to be imprisoned than non-Indigenous people.

Table 1: Numbers of prisoners by state/territory, sex and Indigenous status, Australia, 30 June 2012
 SexIndigenous statusAll people
MalesFemalesIndigenousNon-IndigenousNumber%
Source: ABS, 2013 [1]
Notes:
  1. There were 128 prisoners in NSW and six in the ACT with Indigenous status not recorded/reported
  2. Published numbers for the states and territories were not broken down by sex and Indigenous status
  3. Total percent may be more than 100% due to rounding
NSW 8,977 668 2,205 7,312 9,645 33
Vic 4,544 340 371 4,513 4,884 17
Qld 5,118 475 1,663 3,930 5,593 19
WA 4,518 446 1,969 2,995 4,964 17
SA 1,944 133 475 1,602 2,077 7
Tas 451 43 70 424 494 2
ACT 299 14 46 261 313 1
NT 1,331 80 1,182 229 1,411 5
Australia 27,182 2,199 7,981 21,266 29,381 100
What is a ‘rate‘?

One way of looking at how common a something – like imprisonment or an illness – is in a population is by calculating a 'rate'. A rate is calculated by dividing the number of cases by the population, for a specific amount of time. By calculating rates, you can compare how common it is in different populations (like Indigenous and non-Indigenous people) or between sexes (men and women).

Different states and territories had different rates of imprisonment. After adjusting for the differences in the age structures of the Indigenous and non-Indigenous populations, Tasmania had the lowest Indigenous imprisonment rate (485 prisoners per 100,000 population) and WA had the highest rate (3,390 per 100,000) in 2012 (Table 2) [1].

Table 2: Age-standardised imprisonment rates, by Indigenous status and jurisdiction, and Indigenous:non-Indigenous rate ratios, Australia, 2012
 Indigenous statusRate ratioTotal population
IndigenousNon-Indigenous
Source: ABS, 2013 [1]
Notes:
  1. There were 128 prisoners in NSW and six in the ACT with Indigenous status not recorded/reported
  2. Rates per 100,000 population
  3. Rate ratios is the Indigenous rate divided by the non-Indigenous rate
NSW 1,883 140 13 171
Vic 1,444 108 13 112
Qld 1,359 120 11 159
WA 3,390 169 20 267
SA 2,180 139 16 160
Tas 485 128 4 125
ACT 1,246 85 15 107
NT 2,258 173 13 826
Australia 1,914 129 15 168

Between 2009 and 2012, the total number of prisoners in Australia increased only slightly by 0.2%, but the number of Indigenous prisoners increased by 8% [1][2]. The offender population is even larger if those in the wider criminal justice system are counted (these include people under arrest and held in lock-ups; appearing before the courts; periodic detainees; juvenile offenders not in detention; and those serving community orders). For example, in 2010-11 an average of 56,056 offenders per day were serving community corrections orders [3].

What historical factors have an impact on offender health?

Before the arrival of the First Fleet in 1788, Indigenous people had their own laws and customs. After the arrival, Indigenous people became part of the British Empire and subject to the control of a foreign legal system that was not well understood and was different than their traditional laws [4]. As European settlement spread across the country, Indigenous people were affected by the legal system in many ways including:

Indigenous people have continued to be over-represented in prisons. For example, in WA in 1949, Indigenous people made up 9% of the male and 12% of the female prisoner populations [6]. In 2007, Indigenous people made up 43% of the prison population but made up only 4% of the general population in Australia [7].

In the 1970s and 1980s, after public drunkenness became decriminalised (it was no longer a criminal offence) [8], the rate of imprisonment was reduced. As recommended by the Royal Commission into Aboriginal Deaths in Custody (RCIADC), sobering-up centres were established across Australia and the number of people imprisoned for public drunkenness declined.

What is the social context of offender health?

The factors contributing to the poor health of Indigenous people should be seen within the broader context of the 'social determinants of health' [9][10]. The social determinants of health is a term used to talk about factors that affect people's lives, and affect people's health. These determinants include: income, education, employment, stress, social networks and support, social exclusion, working and living conditions, and gender. Related to these are cultural factors, including: traditions, attitudes, beliefs, and customs. Together, these social and cultural factors have a major influence on a person's behaviour.

Determinants that have been shown to impact on Indigenous offending behaviour include:

There is debate about whether racism plays a role in the number of Indigenous people sentenced to prison instead of diverted into other options, like drug and alcohol treatment programs. The most recent evidence indicates that there is no difference between the sentences given to Indigenous and non-Indigenous people, but the high imprisonment rates for Indigenous people are due to higher rates of violent offences and re-offending [15][16]. There is some evidence that Indigenous young offenders may be less likely to receive diversionary (non-court related) outcomes than non-Indigenous young offenders [15]. Since being in prison as a young person is strongly related to being in prison as an adult, it is important to consider the impact that this might have on later overrepresentation of Indigenous adults in the correctional system [17].

What environmental factors impact upon offender health?

Many Australian prisons are overcrowded which makes it harder to maintain a safe and healthy environment for prisoners [18]. One result of overcrowding is the frequent movement of prisoners between facilities, which makes it hard to maintain consistent physical and mental health interventions. This also makes it very difficult for family members to visit prisoners. In overcrowded prisons, there is a greater risk of transmission of airborne and respiratory infections, which can be a danger to pregnant women and people who are HIV positive [18].

What is known about deaths in custody?

The RCIADC was established in October 1987 as a result of growing public concern about a large number of Indigenous people who died in custody during the 1980s [19]. The RCIADIC investigated each death individually and also investigated the 'larger social and economic factors which might help explain Aboriginal deaths in custody' ([20], p.2). The RCIADC's final report, completed in April 1991, contained 339 recommendations [20]. Positive outcomes from the inquiry include:

The RCIADC found that the rate of deaths in custody for Indigenous people was no higher than for non-Indigenous people. Indigenous Australians were not more likely to die in custody than non-Indigenous Australians, but Indigenous people were significantly overrepresented in custody. The problem was 'too many Aboriginal people are in custody too often' ([7], p.1).

Of the 74 deaths that occurred in custody in 2007 (45 in prison custody, 29 in police custody and custody-related operations), nine (12%) were Indigenous (five in prison custody, and four in police custody and custody-related operations). In the 27 year period from 1980 to 2007 there were 1,206 deaths in prison, 745 in police custody and custody-related operations, and 17 deaths in juvenile detention centres. Indigenous people accounted for almost one-fifth (19%) of these deaths. Since the RCIADC, Indigenous people have continued to be overrepresented in custody in all Australian states and territories [2][7].

The health of Indigenous prisoners

What is known about the general health issues of Indigenous prisoners?

The health of offenders is worse than that of the general population. Two recent health surveys give a good picture of the health of Indigenous prisoners. The 2009 NSW inmate health survey, in which 966 inmates were asked to answer questions about their health, reported:

The best national picture of offender heath is The health of Australia's prisoners 2010 [11]. The data in this report is mostly from the National Prisoner Health Census which collected information in 2010 from: 610 prison entrants, almost 6,000 prisoners in custody who visited a clinic, and over 5,500 prisoners who were taking prescribed medication in Qld, WA, SA, Tas, the ACT and the NT. Of the prison entrants, almost  half (43%) were Indigenous. This report showed:

These two major studies collected information on the general prison population not specifically the Indigenous prison population, however, a recent study of prisoners in NSW found there were not many differences between Indigenous and non-Indigenous prisoners in self-reported chronic health conditions [23].

A recent study found that prisoners with an intellectual disability had worse health than non-disabled prisoners, especially for heart disease, hearing problems, and epilepsy [24]. Indigenous prisoners were over-represented among prisoners with intellectual disability.

What is known about the mental health of offenders?

Mental health is one of the most important issues in offender health. People with mental illness are often imprisoned rather than treated, often because there are not appropriate mental health and related services [25]. Prisoners have much higher rates of mental health conditions than the general population, with some conditions five times more common among prisoners [26]. This difference is often greater for female prisoners than for male prisoners. The difference between prisoners and the general population is greatest in the area of substance use disorders [27]. The following general facts are known about the mental health of offenders:

What is known about the mental health of Indigenous offenders?

There is very little information known specifically about the mental health of Indigenous prisoners. The largest survey was in 2008 in Qld and included 419 Indigenous prisoners (347 men and 72 women) [32]. Among these Indigenous prisoners, most of the male (73%) and female (86%) prisoners suffered from at least one mental health disorder. The most common disorders were substance misuse disorders, anxiety disorders, depressive disorders, and psychotic disorders.

A survey carried out in NSW prisons in 2001 included 277 Indigenous prisoners as part of a total sample of 1,470 prisoners [33]. This study found no difference between the mental health of Indigenous and non-Indigenous male prisoners, except for depression which was lower among Indigenous than among non-Indigenous male prisoners. Indigenous female prisoners, however, had higher levels of psychosis and psychological distress than non-Indigenous female prisoners.

What is known about substance use among offenders?

Substance use is a large problem in offender health. It has been reported that people who have been in prison are more than five times as likely to have a substance use disorder than people who had never been in prison [30]. There is some evidence that substance use is responsible for a large proportion of offending behaviour; some studies estimate that over half of prisoners have had a substance use disorder [34]. The Drug use monitoring in Australia: 2009-10 annual report on drug use among police detainees reported that two-thirds (66%) of adults who were tested while detained by the police had positive a result for at least one drug [35]. Almost half (47%) of people arrested across Australia said they had consumed alcohol in the 48 hours before their arrest. Women detainees were more likely than men to test positive to certain drugs like amphetamines, opiates and benzodiazepines, but men were slightly more likely to test positive for cannabis. Drug use monitoring in Australia: 2007 annual report on drug use among police detainees reported that more than two-thirds (68%) of Indigenous adults who were tested while detained by the police had positive results for a range of drugs [36]. Almost two-thirds (64%) of people arrested across Australia said they had consumed alcohol in the 48 hours prior to their arrest. Australia-wide, women prisoners were more likely than men to test positive to any drug. There is a large overlap of harmful drinking and testing positive to illicit drugs; two-thirds (65%) of people who self-reported that they drink at a harmful level also tested positive to one or more other drug. In this survey the authors concluded that drinking played a bigger role in the offending behaviour of Indigenous people than non-Indigenous people.

The 2010 national prison entrants bloodborne virus survey reported that of the 873 entrants surveyed  [37]:

There is a well-established link between alcohol and offending behaviour. The prisoner population is often characterised by high rates of risky drinking [38]. The health of Australia's prisoners 2010 found almost three-quarters (73%) of Indigenous entrants and almost half (48%) of non-Indigenous entrants reported drinking alcohol at harmful levels in the previous 12 months [11]. Tobacco smoking was also very common among offenders, with three-quarters of Indigenous entrants (74%) and non-Indigenous (75%) smoking cigarettes daily.

What is known about blood-borne viruses and offenders?

Some behaviours, like injecting drug use, tattooing and body piercing, physical violence, and unprotected sex, put a person at high-risk for blood-borne virus (BBV) transmission [39]. Many of these behaviours are more common in prisons than in the wider community. Estimates suggest that between 7,500 and 10,000 prisoners had hepatitis C (HCV) in 2005 [40].

The 2010 national prison entrants' bloodborne virus survey included all jurisdictions and covered 29 reception centres across Australia [37]. This survey reported that:

Transmission of HCV in prison has been documented but few prisoners receive treatment for this virus [39][41]. Allowing HCV-positive prisoners access to treatment is necessary to reduce the risk of infection for other inmates, and for the wider community after their release [42].

What is known about the sexual health of offenders?

Prisoners are a high-risk group for sexual ill-health [43][44]. Offenders often engage in a range of risk-taking behaviours for sexually transmitted infections (STIs) before and after entering prison, including substance use, alcohol consumption, tobacco smoking, and being involved in acts of violence [45]. Prisoners generally come from the most disadvantaged groups in the community, which are recognised as having poor sexual health [46]. There are a number of key issues relating to the sexual health of prisoners, including [18]:

What is known about sexually transmitted infections among offenders?

Prisoners have been shown to have very low rates of contraception use prior to entering prison [47]. High rates of STIs (such as syphilis, HIV, hepatitis B, and some types of herpes) have been reported in the prisoner population [48][49][50]. Often testing procedures are not properly put in place within prisons and therefore the true level of STIs and BBVs are not known. Thorough assessment and referral for treatment on admission to a prison is an important strategy for improving health care for all offenders.

What is known about sexual assault in prisons?

Sexual assault is common among prisoners and has negative short and long term effects, including increasing mental illness and drug misuse. The most comprehensive source of information on sexual assault is the 2006-2007 NSW prisoner telephone sex survey. Inmates were asked whether they were afraid of or had experienced sexual violence while in prison [47]. The inmates reported [47]:

What is known about women prisoners?

According to the June 2012 prison census, there were 2,199 female prisoners in Australia (Table 1) [1]. The imprisonment rate for females was less than the rate for males: 25 female prisoners per 100,000 female adults, compared with 315 prisoners per 100,000 male adults. But imprisonment rates in the last decade have increased for females: between 2002 and 2012 the imprisonment rate for females increased from 19 to 25 per 100,000. The following general facts are known about Indigenous females in prison:

According to The health of Australia's prisoners 2010, female prison entrants differed from male prison entrants in the following health areas [11]:

What is known about juvenile offenders?

Only about 5% of young Australians are Indigenous, but 54% of young people in juvenile detention are Indigenous [7]. During 2007-08, WA had the highest Indigenous youth detention rate in Australia at 880 per 100,000 persons aged 10-17 years, followed by NSW (585 per 100,000), and SA (442 per 100,000). In 2007-08, 40% of juveniles under supervision (e.g. on a community supervision order) were Indigenous [52]. Similarly, over one-half of the people in detention and 60% of the people in remand (not yet sentenced) were Indigenous. Indigenous offenders are more likely than non-Indigenous offenders to begin regularly committing serious offences at younger ages [53]. This makes them more likely to have a history of juvenile detention and to be imprisoned as an adult .

Indigenous juvenile offenders have been shown to:

What is known about the health of inmates after release?

Being in prison separates a person from their home and community and often breaks the bonds between that person and wider society. Offenders re-entering the community need on-going care and support to help them readjust to being part of wider society, especially in areas such as employment and housing. Often the programs offered to offenders do not provide the through-care needed to help them make this transition. This can lead to negative health outcomes; factors like homelessness and drug use are associated with re-offending and returning to prison [57].

A study of the risk of death after release from prisons in WA found Indigenous prisoners have a significantly higher rate of death than did non-Indigenous prisoners [58]. In this study:

Concluding comments

Contact with the criminal justice system presents an opportunity to identify and treat the physical and mental health problems of a group which is economically and socially disadvantaged. But prison health services largely operate without a rehabilitative focus, and the rehabilitation that is offered is often under-funded and poorly designed [59]. The health services offered often fail to account for the specific needs of Indigenous offenders, despite the large proportion of Indigenous offenders within the criminal justice system. Diversion programs for young offenders that help build their skills and resilience, and prevent them entering a cycle of re-offending, is the best way to reduce the over-representative Indigenous incarceration rate in Australia.

There is a clear need to create more diversionary measures when dealing with Indigenous offenders. 'Justice reinvestment’ is a new approach that aims to reduce the high rates of offending and the associated financial costs. This new approach involves a political decision not to build new prisons so that some of the funds are diverted to local communities that have a high concentration of offenders. These funds can then be spent on programs and services that address the underlying causes of crime.

Justice reinvestment has been successful in the United States of America [60] but there is not a lot of evidence to show that it will be successful in Australia. There are currently two major research projects being undertaken to examine how justice reinvestment could work effectively in Australia [61][62][63].

Indigenous offenders are part of the larger Indigenous population in Australia, a population that has lower health outcomes and life expectancy than the general population. To address this, the Council of Australian Governments (COAG) committed to 'closing the gaps' in disadvantage between Indigenous and other Australians [64]. COAG agreed on a number of specific targets and identified ways to monitor progress. Currently, no targets specifically focus on the over-representation of Indigenous people in the criminal justice system, though a number of organisations are working on its inclusion. If this is included as a target, it will need to be thoroughly implemented, monitored and evaluated. The gaps between Indigenous and other Australians will only be closed when all aspects of Indigenous disadvantage are addressed, including Indigenous offending.

References

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Endnote

  1. Asthma and cardiovascular disease prevalence increase with age, this is one possible explanation for the differences found between the inmate population and the general population.

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