This story is part of Prism’s series on incarceration as gendered violence. Read the rest of the series here

At Massachusetts Correctional Institute-Framingham (MCI-Framingham), incarcerated women lose more than their freedom. Many say that during their time there, they also lost the ability to control medical decisions that would have long-term impacts on their mental and physical health.

Since 2008, Professor Susan Sered has been following 47 currently and formerly incarcerated women as they navigated life both inside and outside of MCI-Framingham. Of those she’s spoken to, several told Sered they were prescribed psychiatric medication but were not always informed exactly what they were being given. During phone calls, some would read Sered the name of the medication and ask her to search it online for them. Sometimes the medication they received had a different name from what either of them were familiar with due to a misprint on the prescription label.

“Some women knew what they were being prescribed and some didn’t,” said Sered. But the lack of informed consent went far beyond just medication names. “In terms of the effects that would have on their bodies? No, I don’t think anybody was told anything like that,” said Sered.

Over the last 12 years, Sered, a professor of sociology at the University of Suffolk in Boston, has observed the role of psychiatric medication in these women’s lives and the degree to which key medical decisions were made without their knowledge. Her findings at MCI-Framingham are a snapshot of a phenomenon playing out in prisons across the country. 

Decades of shuttering mental health hospitals and public policy that criminalizes mental illness have turned prisons into American society’s answer to mental illness.

According to the Treatment Advocacy Center, in 44 states, jails or prisons hold more mentally ill individuals than the largest remaining state psychiatric hospital. Nationwide, the three biggest mental health centers are jails: Los Angeles County Jail, Rikers Island, and Cook County jail. Indeed, people with mental illnesses like schizophrenia are 10 times more likely to be in correctional confinement than a hospital bed.  

As a result, high proportions of incarcerated people struggle with disorders that may require medication. In Massachusetts, where Sered is conducting her study, data from the state Department of Corrections showed that 180 women were incarcerated in the state, 84% of whom have open mental health cases and 71% of whom were prescribed psychiatric medication.

However, emerging research suggests that prescription of psychotropic drugs in prisons has expanded beyond medical need and in some cases is being used as a method to punish and control women. Stories from women inside reveal that not only are women frequently left unaware of what they are being prescribed, its potential side effects, and information on whether they are receiving proper dosages, but also that the prescription of this medication can create new dependencies that prison and jail staff don’t help these women properly manage.

“They often just give big doses of stuff that quiets people down”

According to data from the Bureau of Justice Statistics, 67% of incarcerated women report having mental health issues, versus 38% of men. But beyond the higher rate of mental health issues amongst incarcerated women, Sered also says that prison staff harbor misperceptions about women’s behavior, which may make them quicker to overmedicate within women’s facilities.

“I’ve interviewed numerous guards who work in prisons, who tell me that they’d much rather work in a men’s prison than in a women’s prison,” said Sered. “I hear the same thing from all of them: ‘With the men, at least you know where they are, you know? They’ll punch you, they’ll throw something at somebody, but with the women, it’s always stabbing in the back and sneaky and underhanded.’”

Sered notes this is “really, really stereotypical, sexist language but I think there’s a sense in the prisons, that these women are just really awful to deal with.”

When these sexist perceptions of incarcerated women and the desire to temper their behavior are met with understaffed and underfunded prison mental health services, an environment is created where the practice of overmedication can thrive.

“The kind of careful process that your psychopharmacologist or my psychopharmacologist might go through to figure out exactly the right dosage of medication to help—but without having bad side effects? In prison, they don’t have time for that,” said Sered. “So, they often just give big doses of stuff that quiets people down.”

The kinds of drugs prescribed can be powerful. Psychiatric or psychotropic drugs—like Seroquel, Venlafaxine, and Zoloft—are psychoactive medicines that impact the neurological and nervous systems and are used to treat certain mental illnesses. When prescribed, they can improve the mental health of those suffering from issues ranging from mood disorders to schizophrenia, but misdiagnosis or overmedication can result in adverse side effects such as drowsiness, nausea, seizures, depression, and suicidal ideation.

The medication may also increase the likelihood that women will face more punishment while incarcerated, as side effects like fatigue and lethargy put them at risk of reprimand for not being able to complete basic tasks like making their bed properly or arriving to meals or other activities on time.

Researcher and UC San Diego doctoral student Boke Saisi says this suppression also makes women increasingly vulnerable to being sexually abused or assaulted while inside.

“Feminist arguments about incarceration are that prison itself is a form of gendered violence,” said Saisi in an interview with Prism. “And so we can see that replicated through the use of psychotropics and it producing vulnerability to assault by guards and also, this idea of behavioral control.”

Saisi, whose research explores mental health, incarceration, and the contemporary impacts of slavery and colonialism on incarcerated Black and Indigenous women, has been looking at newsletters compiled by incarcerated and formerly incarcerated people in women’s prisons from the late 1970s and 1980s. In these pages, the women speak about how psychotropic drugs were being used as punishment for “participating in acts that are outside of ‘prison protocol,’ which can be a variety of things—just really exercising your bodily autonomy,” Saisi explained. She also says that in these newsletters, drugs were cited as ways to quell dissent and regulate and pathologize peoples gender expression and sexuality—particularly same-sex relationships.

Released, but with new dependencies

Overmedication isn’t the only way prisons are failing women with mental illnesses when it comes to medication. Women who were incarcerated at MCI-Framingham told Sered that their time in prison only further deteriorated their mental health.

These mental health challenges were due in part to the trauma of losing their children while in prison, as well as how the facilities mishandled preexisting substance dependencies. During her research at MCI-Framingham, Sered found that staff took all of the women off their medication upon entry in order to assess what their “baseline behaviors” were. However, when these women—some of whom were on a variety of psychiatric medications prior to their incarceration—were required to go cold turkey, they experienced what Sered was told felt like “a worse withdrawal than heroin.”

During their incarceration, some of these women were gradually given new medication, but since typical sentences for these women are relatively short—often less than six months—their new medication was often not even stabilized by the time they were released. Further, Sered recalls that additional medication was not given to some women upon their release. They were instead told to get a refill from their doctor—a rather low priority task when reconnecting with one’s kids or securing housing were more immediate needs.

In developing new dependencies on medication that they would not have immediate access to, these formerly incarcerated women found themselves at a heightened risk of experiencing withdrawal symptoms that could inhibit their success in landing back on their feet.

Big Pharma and the prison industrial complex

Psychiatric drug prescriptions in prisons are a big business. According to data collected from 11 state departments of corrections in 2015, 10 reported that drug spending accounted for anywhere between 15% and 32% of their total health budgets. Spending on psychiatric drugs in particular was high though it varies widely from state to state. For example, between 2009 and 2011, California spent 26% of its pharmaceutical drug spending on psychotropic drugs alone. Meanwhile, New York, Texas and Florida spent 17%, 6%, and 3% respectively.

In recent years, lawsuits and new legislation have sought to curb overmedication and the lack of informed consent, particularly in states where the usage has been more widespread. In 2011, the California state legislature passed a bill preventing incarcerated people from being prescribed psychotropic drugs without their informed consent. That bill came only a year after pharmaceutical company AstraZeneca, was successfully sued for $520 million. The suit claimed that the company was marketing their drug Seroquel to incarcerated people, the elderly, children, and veterans for a variety of illnesses that the drug had never been tested for. The suit argued that these vulnerable populations were being used as “guinea pigs.”

However, the relationship between Big Pharma and the prison industry still draws markedly less public scrutiny than the relationship shared between prisons and major corporations that use incarcerated labor. Saisi says this is due in large part to social attitudes around incarceration and prevailing public trust in medical institutions.

“The kind of punitive logic of supporting the carceral system is that people deserve to be in prison, and so on the one hand, if psychiatric medication is being used as a punitive measure, then I think some people can feel okay with that,” said Saisi. “And on the flip side, if there’s this kind of resounding faith with the medical establishment and particularly with psychiatry, and it’s deemed as health care, then it’s also seen as justified and okay.”

While the exploitation of incarcerated labor merits sustained scrutiny, Saisi notes that this same criticism must also be lent to overmedication within prisons, which “is damaging and reproduces the notion that carceral spaces can somehow be benevolent and provide health care.”

Large-scale divestment in public health infrastructure and the deep relationship between pharmaceutical companies and the prison industry has created a society that treats mental illness with incarceration. When met with gendered ideas around criminality, that combination makes prisons and jails a uniquely dangerous place for women—where the freedom of both their bodies and psyches is never quite guaranteed.

Tamar Sarai is a features staff reporter at Prism. Follow her on Twitter @bytamarsarai.