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Thirteen million Americans have been convicted of felonies and spent time in prison. The prison system now releases an astonishing 650,000 people each year - more than the population of Boston or Washington. In city after city, newly released felons return to a handful of neighborhoods where many households have some prison connection. The so-called prison ZIP codes have more in common than large populations of felons or children who grow up visiting their mothers and fathers in jail. These neighborhoods are also public health disaster areas and epicenters of blood borne diseases like hepatitis C and AIDS. Infection rates in these areas are many times higher than in neighborhoods short distances away. No one can say how many infections begin in prison. But the proportion could be high given the enormous concentrations of disease behind bars and the risky behaviors that inmates commonly practice. They carve tattoos in themselves using contaminated tools borrowed from other inmates. They inject themselves with drugs using dirty syringes. The most common source of infection could easily be risky, unprotected sex, which, despite denials by prison officials, is clearly a regular occurrence behind bars. A recent study of male inmates in several prisons, for example, found that more than 40 percent had participated in sexual encounters with another man. Most of these inmates, by the way, viewed themselves as heterosexual and planned to resume sex with women once they got out of prison. Prison systems in Canada and Europe have tried to cut down infection by making condoms available to inmates. Prompted by research showing that sterile syringes slow the spread of AIDS among intravenous drug users, several countries have actually moved programs that supply clean needles right into the prisons. Public health officials who favor needle exchanges in the United States are fully aware that this country has just emerged from a presidential election that witnessed heightened activism by conservative Christians. Indeed, even nonreligious Americans would prefer to see prisons shut off the flow of illegal drugs and provide addicts with treatment instead of syringes. The condom issue, however, seems somehow less explosive. But as of now, condoms are banned or unavailable in 48 of 50 state prison systems, on the theory that distributing them would condone illicit sex. When confronted with public health data from abroad, American prison officials have blithely suggested that all the fuss is overblown - because there is little sex to speak of in jail. Congress seemed comfortable with this fiction until 2001, when the Human Rights Watch organization issued a grisly report titled "No Escape: Male Rape in U.S. Prisons." The study suggested that rape accompanied by horrific violence was a regular aspect of American prison life. Based partly on the accounts of more than 200 prisoners in nearly 40 states, the report told of prison officials who stood by while sexual predators raped fellow inmates and sometimes sold them - as sex slaves - to gangs and other inmates. The study led directly to the Prison Rape Elimination Act of 2003, which sailed through Congress and was signed into law by President Bush. The law, which requires the Justice Department to collect data on prison rape and develop a national strategy for combating it, provided a much needed mechanism for weeding out sexual predators behind bars. But this law is, at its heart, a public health law. It provides for grants that could be used to underwrite public health initiatives - including sorely needed studies of disease transmission in the criminal justice system. The law has already resulted in fruitful discussions about expanding disease testing and prevention behind bars. Lawmakers find it easy to discuss prison sex in the context of rape because everyone agrees that sexual assault is horrible and needs to be rooted out. The conversation about consensual sex among inmates will be trickier to handle. Even so, the law will inevitably force prison officials to confront all the varieties of sexual contact that public health researchers have known about for a long time. The commission created by Congress to oversee the new law is just getting started. But it has already brought some honesty to the historically dishonest conversation about sexual behavior in prison. Commission members who have spent time in the public health world, for example, are well aware that people who participate in sex behind bars do so for a variety of reasons. Some barter their bodies - and risk disease - in exchange for protection from marauding gangs. Others perform sex acts in exchange for necessities like soap, food and access to telephone calls. Not all sex in prison, however, can be attributed to rape or bartering. Recent research suggests that some of it is consensual among lonely inmates who experience same-sex encounters for the first time - and for many of them, the only time - while in prison. The new law is pushing some states to create new strategies for dealing with sexual assault in prison. But common sense tells us that sex among inmates will not disappear even if rape and coercion are taken out of the equation. That said, prison officials need to revisit rules that outlaw condoms behind bars. These rules aid the spread of diseases that flourish in prison - and then make the leap to the world outside. |
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