Review of Indigenous offender health

What do we know about the Indigenous offender population?

At June 2009, there were 29,317 prisoners in Australia, 93% of which were men [1]. Indigenous prisoners made up 25% of the total prisoner population (Table 1). Indigenous people were 14 times more likely than non-Indigenous people to be imprisoned.

Table 1: Numbers of prisoners by jurisdiction, sex and Indigenous status, Australia, 30 June 2009

	Sex		Indigenous status		All people
	Males	Females	Indigenous	Non-Indigenous	Number	%
Source: ABS, 2009 [1]
Notes: There were 377 prisoners in NSW with Indigenous status not recorded/reported Published numbers for the states and territories were not broken down by sex and Indigenous status
NSW	10,273	854	2,374	8,376	11,127	38
Vic	4,068	282	241	4,109	4,350	15
Qld	5,251	416	1,576	4,091	5,667	19
WA	4,078	341	1,790	2,629	4,419	15
SA	1,839	121	449	1,511	1,960	7
Tas	492	43	66	469	535	2
ACT	180	23	26	177	203	1
NT	1,011	45	864	192	1,056	4
Australia	27,192	2,125	7,389	21,554	29,317	100

Different states and territories had different rates of imprisonment, ranging from 471 prisoners per 100,000 population for Tas to 3,329 per 100,000 for WA (Table 2) [1].

Table 2: Age-standardised imprisonment rates, by Indigenous status and jurisdiction, and Indigenous:non-Indigenous rate ratios, Australia, 2009

	Indigenous status		Rate ratio	Total population
	Indigenous	Non-Indigenous
Source: ABS, 2009 [1]
Notes: There were 377 prisoners in NSW with Indigenous status not recorded/reported Rates per 100,000 population Rate ratios are Indigenous rates divided by non-Indigenous rates
NSW	2,153	164	13.1	204
Vic	968	101	9.6	104
Qld	1,427	129	11.1	168
WA	3,329	163	20.4	261
SA	2,072	133	15.5	155
Tas	471	146	3.2	140
ACT	760	63	12.0	75
NT	1,700	153	11.1	658
Australia	1,891	136	12.0	175

Between 2008 and 2009, the total number of prisoners increased by 6%, and the number of Indigenous prisoners increased by 10% [1]. The offender population is even larger if those in the wider criminal justice system are counted (including 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 2008-09 an average of 56,972 offenders per day were serving community corrections orders [2].

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 [3]. As European settlement spread across the country, Indigenous people were affected by the legal system in many ways including:

• being taken off their lands by police and other legal forces [4]
• being imprisoned for reasons such as stealing sheep and cattle [3]
• being placed in off-shore prisons or settlements such as Palm Island or Rottnest Island [3].

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 [5]. In 2007, Indigenous people made up 43% of the prison population but made up only 4% of the general population in Australia [6].

In the 1970s and 1980s, when public drunkenness became decriminalised (it was no longer a criminal offence) [7], 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' [8][9]. The social determinants of health is a term used to talk about factors that affect people's lives, and that also 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:

• education - Indigenous people who have completed less education are more likely to be imprisoned [10]
• employment and financial stress - Indigenous people who are employed and not experiencing financial stress are less likely to be imprisoned [11]
• living conditions and location - Indigenous people who live in crowded, remote locations or who are homeless are more likely to be imprisoned [11]
• parental imprisonment - children whose parents have been to prison are more likely to go to prison themselves [12]
• living in care - children who are placed in care more likely to be imprisoned [13]
• substance use - Indigenous people who misuse drugs and alcohol are more likely to be imprisoned than those who do not [11].

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 that high imprisonment rates for Indigenous people are due to high rates of violent offences and re-offending [14][15]. There has been some evidence, however, that Indigenous young offenders may be less likely to receive diversionary (non-court related) outcomes than non-Indigenous young offenders [14]. 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 [16].

What environmental factors impact upon offender health?

Many Australian prisons are full or over-full, and overcrowding makes it harder to maintain a safe and healthy environment for prisoners [17]. One result of overcrowding is the frequent movement of prisoners between facilities, making it hard to maintain consistent physical and mental health interventions. In many cases 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 [17].

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 [18]. The RCIADIC investigated each death individually and also investigated the 'larger social and economic factors which might help explain Aboriginal deaths in custody' ([19], p.2). The RCIADC's final report, completed in April 1991, contained 339 recommendations [19]. Positive outcomes from the inquiry include:

• some improvement in the treatment of Indigenous people when arrested and in detention
• the establishment of Aboriginal visitor schemes in some jurisdictions
• the establishment of RCIADC watch committees in some jurisdictions
• the ongoing monitoring of deaths occurring in custody by the Australian Institute of Criminology.

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' ([6], 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 [1][6].

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:

• only one-third (33%) of inmates rated their overall health to be very good or excellent, compared with more than half (56%) of the general population (sampled in the National health survey 2007-2008 (NHS)) [13][20]
• inmates scores were lower than those of the general community across all health measures indicating higher levels of chronic disease
• the difference between inmates and members of the general community was greater for women than for men.

The best national picture of offender heath is The health of Australia's prisoners 2009 [10]. The data in this report is mostly from the National prisoner health census which collected information from 549 prison entrants, over 3,700 prisoners in custody who visited a clinic, and over 4,900 prisoners who were taking prescribed medication [10]. Of the prison entrants, 141 (26%) were Indigenous. This report showed [21]:

• general self-reported levels of chronic diseases for inmates tended to be lower than those in the general population
• almost one-sixth (16%) of Indigenous and non-Indigenous entrants reported currently having asthma (compared with 10% of the general public who reported asthma in the 2004-05 NHS)
• 4% of Indigenous and 6% of non-Indigenous entrants reported arthritis, which is much lower than the 15% reported by the general public in the 2004-05 NHS [21] 1
• 3% of Indigenous and non-Indigenous prisoners reported cardiovascular disease, compared with 18% of the general public
• the rate of diabetes was similar to that of the general public (3.6%) with 4% of Indigenous and 2% of non-Indigenous entrants reporting having been diagnosed as having diabetes
• cancer was reported by less than 1% of all entrants compared with 2% of the general public.

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 [22].

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 incarcerated rather than treated, mostly because of the lack of appropriate mental health and other services [23]. Prisoners have much higher rates of mental health conditions than the general population, with some conditions five times as common among prisoners [24]. 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 [25]. The following general facts are known about the mental health of offenders:

• In 2001, there were approximately 5,000 people with major mental illnesses in prisons [26].
• A 2003 study found that one-fifth (20%) of female prisoners, and one-seventh (14%) of male prisoners reported having had a prior admission for a psychiatric illness; only 0.8% of the general population was hospitalised for mental health problems in 2003 [27].
• The 2007 National survey of mental health and wellbeing estimated that 41% of people who had been in prison had a mental disorder (compared with only 19% of people who had never been in prison) [28].
• The 2007 National survey of mental health and wellbeing found that almost one-quarter (23%) of people who had been in prison reported having had a substance use disorder, including alcohol related disorders (compared with only 4.7% of those who never had been in prison) [28].
• In The health of Australia's prisoners 2009, around two-fifths (41%) of non-Indigenous and around one-quarter (26%) of Indigenous prisoners reported having been told by a medical professional that they had a mental disorder [10].
• The health of Australia's prisoners 2009 reported that one-fifth (20%) of non-Indigenous and almost one-tenth (9%) of Indigenous entrants reported currently taking medication for a mental health disorder [10].
• In 2004 in NSW almost half (43%) of prisoners who were screened had psychosis, anxiety disorder, and/or affective disorders [29].
• The same study found that almost two-thirds (61%) of female prisoners had some form of psychiatric illness, compared with two-fifths (39%) of the male prisoners [29].

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 carried out in NSW prisons and included 277 Indigenous prisoners as part of a total sample of 1,470 prisoners [30]. This study found no difference in the mental health of Indigenous and non-Indigenous male prisoners, except for depression which was higher among non-Indigenous than among Indigenous male prisoners. Indigenous female prisoners, however, had higher levels of psychosis and psychological distress than non-Indigenous female prisoners.

Mental health issues often occur with, and because of, substance use issues. This is a problem for Indigenous offenders. Substance use and mental illness have been linked to the high level of Indigenous offending, particularly violent offending [31]. This contributes to high levels of imprisonment for Indigenous offenders, with violent offenders often not eligible for diversion programs. There needs to be further development of Indigenous specific programs which provide both treatment for substance use and treatment for mental illness.

What is known about substance use among offenders?

Substance use is a large issue 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 as people who had never been in prison [28]. Evidence exists that substance misuse is responsible for a large proportion of offending behaviour, with some studies estimating that over half of prisoners have had a substance use disorder [32]. 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 [33]. 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 2007 national prison entrants bloodborne virus survey reported that of the 749 entrants surveyed [34]:

• more than one-half (55%) had injected drugs at some time in their lives, and of these almost two-thirds (60%) had injected in the previous month
• injecting drug use was more common for Indigenous entrants (61%) than for non-Indigenous entrants (53%), and for female entrants (73%) than for male entrants (53%)
• more than nine-out-of-ten injecting drug users interviewed had injected for more than three years, which suggests that the prisoner population has a lot more long-term drug users than does the general community.

There is a well-established link between alcohol and offending behaviour. The prisoner population is often characterised by high rates of risky drinking [35]. The health of Australia's prisoners 2009 found that two-thirds (65%) of Indigenous entrants and almost half (47%) of non-Indigenous entrants reported drinking alcohol at harmful levels in the previous 12 months. Tobacco smoking was also very common among offenders, with around seven-out-of-ten Indigenous entrants (72%) and non-Indigenous (74%) entrants being daily smokers.

What is known about blood-borne viruses and offenders?

High-risk behaviours for blood-borne virus (BBV) transmission, such as injecting drug use, tattooing, physical violence, body piercing and unprotected sex, are more common in prisons than in the wider community [36]. Estimates suggest that between 7,500 and 10,000 prisoners in 2005 had hepatitis C (HCV) [37].

The 2007 national prison entrants' bloodborne virus survey included all jurisdictions (except the NT) and covered 18 reception centres across Australia [34]. This survey reported that:

• the rate of HIV was low in both men and women (less than 1%)
• more Indigenous than non-Indigenous prison entrants had HCV (43% compared with 33%)
• HCV was much higher among people with a history of injecting drug use than among non-injectors (60% compared with 4%)
• women who had injected drugs had higher levels of HCV than did male injectors (78% compared with 58%)
• almost three-quarters (72%) of Indigenous female entrants tested positive for HCV
• more Indigenous prison entrants tested positive for hepatitis B than non-Indigenous entrants (42% compared with 17%).

The national rates of both hepatitis B and HCV for the total population is less than 1% [10]. Transmission of HCV in prison has been documented but few prisoners receive treatment for this virus [36][38]. 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 [39].

What is known about the sexual health of offenders?

There are a number of key issues relating to the sexual health of prisoners, including [17]:

• prisons being used as an opportunity to screen for and treat STIs
• providing condoms to prisoners in order to prevent the transmission of sexually transmitted infections (STIs) between prisoners (condoms are available in prisons in all jurisdictions except Qld and the NT)
• conjugal visits (conjugal visits are allowed to a limited extent in some prisons in Vic and Tas)
• sexual assault and related victim trauma.

What is known about sexually transmitted infections among offenders?

Prisoners are a high-risk group for sexual ill-health [40][41]. Offenders often engage in a range of risk-taking behaviours for STIs before and after entering prison, including substance abuse, alcohol consumption, tobacco smoking, and being involved in acts of violence [34]. Prisoners generally come from the most disadvantaged groups in the community, which are recognised as having poor sexual health [42]. Prisoners have been shown to have very low rates of contraception use prior to entering prison [43]. High rates of STIs (such as syphilis, HIV, hepatitis B, and herpes simplex virus type-2) have been reported in the prisoner population [44][45][46]. Often testing procedures are not properly put in place within prisons and 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 [43]. The inmates reported [43]:

• around one-in-fourteen (7.3%) male prisoners were concerned about being sexually assaulted
• around one-in-seventeen (5.7%) male prisoners had been threatened with sexual assault
• 2.4 % of male prisoners had experienced sexual violence while in prison
• around one-in-fifteen (6.5%) female prisoners were concerned about being sexually assaulted
• around one-in-fourteen (7%) female prisoners had been threatened with sexual assault
• 4% of female prisoners had been sexually assaulted or frightened into having sex
• physical assault was common; around than one-third of men (34%) and women (27%) reported having been physically assaulted while in prison.

What is known about women prisoners?

According to the June 2009 prison census, there were 2,125 female prisoners in Australia (Table 1) [1]. The imprisonment rate for females was much less than the rate for males: 25 female prisoners per 100,000 female adults, compared with 329 prisoners per 100,000 male adults. But imprisonment rates in the last decade have increased more for women than for men: between 1999 and 2009 the imprisonment rate for females increased by 57% compared with an increase of 35% for males. The following general facts are known about Indigenous females in prison:

• The overall rate of imprisonment for Indigenous females in Australia in 2009 was 360 per 100,000 population, 20 times the rate of 18 per 100,000 for non-Indigenous females [1].
• Indigenous female prisoners were younger than non-Indigenous female prisoners. The median age of all female prisoners was 34.2 years, 2.5 years older than the median age of 31.7 years for Indigenous female prisoners [1].
• In The health of Australia's prisoners 2009, the average age of first pregnancy for Indigenous entrants was 17 years compared with 19 years for non-Indigenous entrants [10].
• The proportion of the female prison population that was Indigenous ranged from less than 10% in Victoria to more than 80% in the NT [1].
• Indigenous female prisoners are more likely to report a history of substance and alcohol misuse than non-Indigenous female prisoners [47].
• Female offenders often also report having experienced sexual, physical and emotional violence from a young age [47].

Female prison entrants differed from male prison entrants in the following health areas in The health of Australia's prisoners 2009 [10]:

• more female entrants reported a history of mental health problems (57%) and self-harm (31%) than did male entrants (35% and 16%)
• female entrants had a much higher prevalence of HCV (60%) and hepatitis B (28%) than did male prison entrants (33% and 21%)
• female entrants had higher rates of all chronic diseases than male entrants.

What is known about juvenile offenders?

Only about 5% of young Australians are Indigenous, but 54% of young people in juvenile detention are Indigenous [6]. 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). On an average day in 2007-08, 40% of juveniles under supervision (for example, on a community supervision order) were Indigenous, as were over one-half of those in detention and 60% of those who were in remand yet to be sentenced [48]. Indigenous offenders are more likely than non-Indigenous offenders to begin regularly committing serious offences at younger ages and this makes them more likely to have a history of juvenile detention and further incarceration as an adult [31].

Indigenous juvenile offenders have been shown to:

• have higher rates of BBV than non-Indigenous juvenile offenders, and juveniles in the general public [49]
• be much more likely to have been placed in care, and up to three times as likely to have had a parent that had ever been in prison [50]
• have higher levels of mental disorders than non-Indigenous juvenile offenders and juvenile members of the general public, including higher levels of self-harm [51]
• have lower levels of school completion and attendance [51].

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 which can lead to negative health outcomes, with factors such as homelessness and ongoing drug misuse being strongly associated with re-offending and returning to prison [52].

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 [53]. In this study:

• Indigenous women prisoners aged 20-40 years were 3.4 times more likely to die than other WA Indigenous women in the same age group
• Indigenous male prisoners (20-40 years) were 2.9 times more likely to die than other WA Indigenous men in the same age group
• the main causes of death overall were related to drug and/or alcohol use
• there was a greater risk of death by suicide or motor vehicle accident among Indigenous men aged 20-40 years than among with non-Indigenous men.

Concluding comments

Contact with the criminal justice system presents an opportunity to identify and treat the physical and mental health problems of a group that is economically and socially disadvantaged. But prison health services still largely operate without a rehabilitative focus, and the rehabilitation that is offered is often under-funded and poorly designed [54]. 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. There is a clear need to embrace more diversionary measures when dealing with Indigenous offenders. Diversion for young offenders into programs that help build their skills and resilience, and prevent them entering a cycle of re-offending, is the best way to reduce the hugely over-representative Indigenous incarceration rate in Australia.

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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.