Abstract
Background:
Older women with criminal legal system involvement (CLSI) are women who are currently or formerly incarcerated or under supervised probation. Older women (age >50) make up about 18% of jail or prison incarcerated females, about 20,000 individuals, and many more in community supervision. Older women with CLSI face disproportionate aging-related health challenges as a result of social determinants and life circumstances that wear away at health over the long term. Research on health in this group is rare, and even rarer for women after incarceration, potentially hindering the development of focused solutions to improve women’s health and access to services.
Objective:
To summarize the research and identify gaps in peer-reviewed research on health and health services use of older women (age <50) with CLSI, we conducted a scoping review following Arksey and O’Malley’s six-step method.
Sources of Evidence:
Searches in PubMed, CINAHL, and EMBASE were conducted, followed by iterative reviews of titles, abstracts, and full-texts.
Eligibility Criteria:
Data-based studies, published January 2000 to January 2025, and focused on women with CLSI, age >50 years.
Charting Methods:
We extracted data into a matrix to summarize study characteristics and thematic emphases, divergences, and gaps.
Results:
Of 25 studies meeting criteria, 12 were qualitative-only; 13 included cross-sectional analyses of health survey or medical record data. We were unable to locate any experimental or longitudinal observational studies. Thematic emphases included physical, mental, and social health and health services use during and post-incarceration; coping strategies, strengths, and resources; and proposed solutions to mitigate health challenges.
Conclusion:
Despite a rising number of older women with CLSI and barriers to aging-related care in and after incarceration, research to understand older women’s needs during and after incarceration is rare, and interventional study to meet them is almost non-existent.
Introduction
The rate at which women are incarcerated increased sevenfold between 1980 and 2024, 1 while during roughly the same time, the percentage of older adults among those incarcerated increased 280%. 2 Compared with older adults who have no criminal legal system involvement (CLSI), older people with current or past CLSI have more chronic disease, functional impairment, mental illness, and early mortality.3–6 Researchers have associated CLSI with aging acceleration, or aging-related health changes that occur at earlier stages than chronological norms. 7 Most studies on aging and health in the context of CLSI rely on all-male or nearly all-male samples. This is not surprising, since women make up a much smaller—though increasing—share of the overall criminal-legal system involved population.
Criminal-legal system involvement (CLSI) includes both current and former jail (typically, ⩽1 year) or prison (>1 year) incarceration and community supervision (i.e., probation or parole). Women comprise about 18% of the U.S. incarcerated population, and women over age 50 represent approximately 18% of women’s incarceration. 8 In 2022, there were nearly 800,000 women in community supervision. 8 Worldwide, women’s incarceration has increased 57% since 2000, with the largest number and the highest rate in the United States, followed by Thailand, El Salvador, and Rwanda. 9 Examination of records of women released from U.S. state prisons in 15 states in 1 year (n = 23,562) indicated a 3-year reincarceration rate of 30%.10,11 For many women and families, serial incarceration contributes to the experience of “churning,” a social and material upheaval of roles and relationships that, over the long term, affects health and complicates access to health care and health maintenance.12(p. 113)
In general, the health status, health services access, and health services use of women with CLSI during incarceration are rarely a focus of research or reform and are almost entirely lost to view post-incarceration. What we do know about the health of women with CLSI suggests they experience physical, functional, and mental health conditions at higher rates, with more complications, and at greater expense than women without CLSI and in some respects more than men with or without CLSI.13–15 Women with CLSI not only bear disproportionately high health burdens when it comes to chronic disease and mental health, but those conditions may go untreated due to social stigma related to incarceration, substance use, or other CLSI-related causes. Many women with CLSI have a history of psychosocial trauma as a result of violence and abuse, which can also affect how, whether, or when women access health care. Competing priorities and discrimination in health care settings may lead to delayed care and worse outcomes. For older women with CLSI, the information about health and access to care becomes increasingly difficult to locate. Data points can be gleaned from studies in which samples are overwhelmingly men or younger women, but research that specifically examines questions of health in aging in women who have had a lived experience of incarceration is rare. To summarize the field and synthesize points of emphasis and divergence in the literature, we conducted a scoping review of work published from 2000 to 2025 focused on answering the question, “What is the literature that addresses the health, health access, and health care use of older women with CLSI?” Our objective was to identify thematic emphases and gaps across the existing work and highlight areas for future research.
Method
Study design
Scoping reviews summarize research in an underdeveloped, undefined, shifting, or novel field of inquiry. 16 Scoping reviews may be conducted to gain a general idea of the landscape of a field of inquiry or evaluate the readiness of the literature for systematic review. Our scoping study followed steps outlined by Arksey and O’Malley: (a) define the topic, (b) broadly search the literature to identify relevant work, (c) chart and summarize the research, (d) analyze themes in the studies to draw implications and outline areas of research need, and (e) obtain feedback from stakeholders with relevant lived or professional experience. 16 We used the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist to guide the design and reporting of this review. 17
Search, selection, and analysis
After defining the study purpose and establishing criteria for inclusion, the first, second, and fifth authors independently searched PubMed, CINAHL, and EMBASE using search terms as outlined in the Supplemental Material. Searches were performed in September 2022, updated in May 2024, and again in January 2025. Articles were eligible if published between January 2000 and January 2025, included a primary focus on women or nonbinary people, AND older adults, AND incarceration or former incarceration or supervised probation, AND any form of health. Older was defined as age 50 and older, following common practice in the field. 7 We included studies in which age ranges began at age 50, with exceptions for two menopause studies with women aged 40 and older and studies where the sample mean age was 50 or older. We excluded studies that reported findings by gender and age but that did not have an analytic focus on the experience of being a woman or nonbinary gendered person aging in the context of CLSI. We included studies in which samples had either current or former incarceration or probation status, as long as the CLSI was a primary sampling or contextual focus. More details on our search process can be found in the Supplemental Material and Figure 1.
Flow diagram.
In screening the literature, the first, fourth, and fifth authors independently and iteratively reviewed titles, abstracts, and full-texts for inclusion and exclusion. The first, second, and fifth authors extracted and charted data from full-texts to characterize the literature, including study design and purpose, use of theory, setting, sampling/sample, method, findings, implications, and conclusions/recommendations. An abbreviated extraction matrix is displayed in Table 1. The first, second, third, and fifth authors read and reread full texts to identify prominent, repeated ideas or emphases. We used a form of thematic analysis 19 to consolidate topics into clusters and then synthesized the literature according to the clusters, adding examples, elucidating gaps, and calling attention to implications. The results were reviewed by all five team members and revised. The authors obtained critical feedback from an older adult woman with lived experience of incarceration and professional experience helping women access and coordinate services after incarceration and a colleague with nearly three decades’ experience in research in the field but not involved directly in the review.
Description of the sample.
ADL: activities of daily living; BMI: body mass index; CLS: criminal-legal system; CLSI: criminal legal system involvement; EFP: elderly female prisoners; PADL: prison activities of daily living; TDAS: Templer Death Anxiety Scale.
Results
Sample description
Of the 25 studies included, 19 were conducted in the United States,3,5,20–23,25–27,29–33,35,36,38,41,42 and one study each in Brazil, 24 Canada, 40 Pakistan, 34 Philippines, 37 Switzerland, 28 and the United Kingdom. 39 Twenty studies addressed older women’s health or health care during a prison incarceration20–25,28–39,41,42; five studies analyzed self-reported health or health services use after incarceration in prison or jail.3,5,26,27,40 Samples of women with CLSI ranged in size from 4 to 1120 participants. In 19 of the 25 studies, the samples were all women; one study included individuals who identified as transwomen 32 and two studies included men,5,35 but the analytic emphasis was on older women. Three studies collected data about older women from health services and other professionals and advocates who worked with them or on their behalf during or after incarceration.23,39,40 In one study, where the unit of analysis was institutional, the authors compared health services in all-women facilities having a higher proportion of younger women with those facilities having a higher proportion of older women. 38 In studies in which race was reported and the unit of analysis was women during or after incarceration, samples were 31%–100% women of color. The mean age of the pooled samples, from those that reported an average, was 57.4 years; ages ranged 50–95 years, except two studies on menopause that included people aged 40 and older30,34 and one study that included respondents as young as 22 but had an average age of 50.7 and emphasized implications for aging. 41
Study designs were descriptive and included both qualitative and quantitative approaches. There were 13 cross-sectional studies, including four that analyzed pre-existing survey data and three in which data were gleaned from medical records. One study was a program description that included women’s evaluation of a prison-based, small-group art therapy program. 29 We did not find any experimental studies or prospective studies or studies that analyzed time series data. Researchers collected new data via interviews or investigator-developed surveys; a few administered pre-existing instruments or scales. Among the latter, two studies drawing on the same data set,20,25 reported on results of the Brief Symptom Inventory 43 ; Hopkins Symptom Checklist 44 ; and Templer Death Anxiety Scale. 45 In the studies with qualitative components, investigators collected data in focus group interviews, 23 nominal groups, 39 individual interviews,22,24,27,28,30,32,33,37,40,41 text responses to open-ended questions on surveys,21,25,29,42 and participant observation. 32 The three studies that featured individual or group interviews with others about older women with CLSI, included family members, 40 area experts and health agency leads, 39 and facility staff and health or social services providers who had direct interaction with older women, either during incarceration 23 or during reintegration to the community after being released. 40
Theory
Theories and concepts that authors used to frame descriptions or explanations of women’s experiences of criminal-legal system involvement included references to classic sociology of crime models such as importation theory, 20 deprivation theory, 20 and strain theory. 40 Researchers also theorized the positionality of older women with CLSI through social determinant lenses of intersectionality and standpoint feminism5,33,40; Black Feminist Epistemology 33 ; pathways theory 27 ; and layers of vulnerability. 28 Psychological theories were offered in some sources to explain women’s responses to life challenges in and out of incarceration, such as accumulated stress 3 and behaviorism, locus of control, social learning theory, tend-and-befriend theory, and disaster syndrome. 29 Specific to aging and health, Lucas et al. 37 developed a grounded theory that the authors situated in relation to Rowe and Kahn’s 46 “successful aging” model. Latham-Mintus et al. 5 and Emerson et al. 3 applied a life course perspective. Some invoked concepts related to theory, such as “aging in place,”21(p. 370) “spiritual turning points”22(p. 243); Goffman’s concept of total institution; and Sykes’s pains of imprisonment.20,25 Thirteen studies did not identify a theory.23,24,26,30,31,32,34–36,38,39,41,42
Thematic emphases
We discerned five thematic emphases in the articles: acknowledging the unacknowledged; effects of sociodemographic factors and life circumstances; health during and after incarceration; coping strategies, strengths, and resources; and recommendations to reduce health barriers.
Acknowledging the unacknowledged
Nearly all the sources we reviewed began and/or ended with specific reference to the relative invisibility in health research of older women with CLSI. This idea often organized background descriptions in which authors offered a rationale for their work. Most sources cited a lack of research to understand or document the needs of older women and/or the failure of the public to appreciate the magnitude of challenges faced by older women with CLSI. Emblematic of these descriptions was Aday and Farney’s 21 eponymous reference to older women’s plight—“Malign Neglect”—the phrase itself taken from Michael Tonry’s 47 book on the criminalization of race and later in referring to policies and programs for older women with CLSI by Williams and Rikard. 48 Other sources noted a continuing absence of provision for older women’s health in policy5,39 and a lack of attention to older women in reentry programming. 40 In some cases, authors described the public’s indifference to the health and health services access of older people with CLSI as having reached a crisis point, especially in the state prison system.32,38 Four sources alluded to rising economic costs of providing health services to older people in prison as a growing fiscal threat.35,36,38,42 James et al., writing about older women’s mental health in prisons during the COVID-19 pandemic, narrated a realized disaster, citing the COVID-19 shutdowns in California state prisons as having “perpetuated a crisis [that was] already brewing in U.S. prisons.”32(p. 10)
Effects of sociodemographic factors and life circumstances
Another common emphasis in our sample was sociodemographic factors and life experiences as conditioning elements or predictors of health in older women with CLSI.20,24,25,28,35,36,42 These so-called “pathway” determinants ranged from individual and interpersonal to social and systemic. Authors considered how demographics like race, gender, and age function as independent variables or covariates in predicting physical and mental health conditions—in older women with CLSI alone, in comparison with men, and in comparison with younger women with CLSI. Leigey and Johnston 36 found race and age in older women who were imprisoned to be significantly related to both healthy weight and obesity (but not to being overweight). Aday and Dye 20 identified age and race as significant predictors of depression in a sample of 327 older women in seven state prisons. In Aday and Farney’s 21 analysis of the same data, race was associated with chronic illness, daily medications, and self-perceived health in prison over two years. Deaton et al. 25 reported that age but not race was a significant predictor of differences in death anxiety in older women in prison. In more recent work, Latham-Mintus et al. 5 applied intersectionality and life course perspectives to analyze the layered effects of race, gender, and socioeconomic status in an analysis of nationally representative, sample-weighted secondary data from the Health and Retirement Study. The team found race and gender to be significantly associated with depressive symptoms and physical limitations, independent of early life trauma and lifetime stressful events. Lane et al. 35 analyzed relationships between age and gender and mental and physical health in older adults in four state prisons and found that being female was linked to having more prescribed medications and more mental and emotional diagnoses. Aside from arthritis, gender was not a statistically significant predictor of other physical health conditions. 35
Lifetime trauma from chronic or acute violence and/or abuse was a particular life experience that authors described as intertwined with health in older women with CLSI, during and after incarceration. James et al. 32 underscored how the enforced isolation and disruption of supportive relationships during COVID-19 shutdowns in California state prisons exacerbated trauma- and anxiety-related mental health challenges in older women. Aday and Dye 20 similarly noted how trauma, combined with social-relational deprivations of prison, impacted the coping of older women. The participants in Emerson et al. 27 described women’s perceptions of how violence and trauma during young adulthood influenced their attitudes and behaviors in forming intimate relationships later in life. Responses to Hongo and Valenti’s 29 art therapy intervention for older women during incarceration suggested that older women found value in artistic activities because these provided novel means to cope with trauma symptoms. In contrast, among studies in which health data were collected in surveys and from medical records, only Aday et al.’s studies20,21,25 and Emerson et al.’s 3 secondary data analysis of Health and Retirement Study data included measurement of violence and/or trauma (e.g., the Aday studies asked if the respondent had been hit with a fist, forced to have sex, threatened with their life). Whereas psychosocial trauma was frequently mentioned in the introduction and discussion sections and could be inferred from qualitative results, few of the studies that collected quantitative data reported older women’s trauma exposures or symptoms.
Health during and after incarceration
Physical and functional health
Older women’s physical health status during incarceration was among the most common areas of emphasis across articles. Thirteen sources, over half, reported on older women’s physical and functional health status based on medical record review or surveys administered during or after an incarceration (see Table 2). The most frequently reported physical conditions in the quantitative research were hypertension (n = 9), diabetes (n = 9), cardiovascular disease (n = 8), and unspecified chronic disease (n = 9). Functional health included activities of daily living, mobility, strength, energy (fatigue), sensory (i.e., vision and hearing), continence, and cognition. A few sources reported qualitatively on women’s experiences of coping with functional health challenges during imprisonment. In these studies, women, 42 support services and agency personnel and custody staff 23 described built environment, social, and programmatic obstacles to healthy function in carceral spaces. Six studies addressed symptoms of menopause transition21,24,25,31,34,38 and, in three studies, older women described particular functional health challenges of managing menopausal transition during imprisonment, specifically symptoms related to vasomotor, cognition/memory, vitality (i.e., exhaustion), and vision/hearing changes.24,31,34
Sources reporting survey and medical record data on physical, functional, and mental health.
Incarceration was not only characterized as a setting in which women with CLSI struggled to manage pre-existing physical and functional health vulnerabilities. In most of the studies, incarceration emerged as an active force that could precipitate or amplify physical and functional health risk. The physical environment of incarceration was described as sleep averse—both noisy and lacking in privacy.21,23,33,39,42 Three studies in the review noted particular struggles with sleep in women in menopausal transition.24,30,34 Several studies emphasized how prisons and jails as built environments offer few physical accommodations for those with functional impairments. Older women and the staff and providers who interact with them during incarceration reported older women’s difficulty climbing stairs and accessing top bunks.21,23,28,39,42 Health self-maintenance was identified as a particular struggle during incarceration: sources cited a lack of screenings for chronic disease,28,33,39 preventive dental care, 41 nutritious food options,28,33,36,38,41 and opportunities for physical activity.24,28,36 Studies described the unavailability or rationing of health-related supplies, including appropriate footwear and bedding 23 and, for women experiencing menopausal transition symptoms, fans, sanitary pads, and replacements for affected undergarments. 30 Several studies cited direct evidence or inferred from findings that prison work assignments outside of women’s functional ability compromised older women’s physical health and safety.23,28,41,42 James et al. 32 observed that older women in prison during the COVID-19 shutdown—though more susceptible to a dangerous course of disease—could not maintain healthy social distancing, access adequate sanitation, or find space for physical activity.
Mental health during incarceration
An equally prominent topic was older women’s mental health status and risk during incarceration. We identified mental health during incarceration as an outcome in 12 of 13 of the cross-sectional studies reporting health outcomes, 11 of which included measurement or self-report of depression or its symptoms (Table 2).3,5,20,21,25,26,31,34,35,38,42 Describing depression in older women in prison was the purpose of Aday and Dye’s 20 study, which identified determinants of women’s depression based on competing models of importation (i.e., what women brought to imprisonment) and deprivation (i.e., what was brought about by imprisonment). Factors from both categories were combined in a model that explained 52% of variance in depression. Anxiety was reported in several studies. Deaton et al. 25 examined death anxiety in older women with life sentences, which manifested as fear of health deterioration while imprisoned; not having access to adequate health services; not being able to contact, reassure, or reconcile with family; and dying without dignity. Anxiety, depression, and suicide in older women while incarcerated were specifically related to women’s fears about not having access to necessary health services in Aday and Krabill, 22 James, 33 and Reviere and Young. 38
Social health during incarceration
The several studies that addressed social health during incarceration focused on associations between well-being in older women and their sense of connection, engagement, or relationship with other women in jail or prison, family and friends on the outside, health providers, and facility staff. Social well-being was linked to women’s cognitive status, 23 mobility and sensory functional abilities, 42 and menopausal transition. 24 Older women experienced challenges to social well-being that arose from a lack of empathy from facility staff and health care providers23,28; fear of being victimized by staff and other incarcerated individuals35,42; and lack of appropriate group activities and programming.23,28,35,39 Four studies referred to disruption of family roles (e.g., as carers for parents, children, grandchildren)23,39 or deterioration of relationships25,28 because of the distance of prisons from urban centers and social networks.
Health post-incarceration
Eight studies collected data on the health of women who were previously incarcerated.3,5,26–28,38,40,42 Studies of older women living in the community after incarceration identified many of the same physical, mental, and social health challenges as older women in jail and prison, with some differences. Shantz and Frigon 40 described older women’s struggle to achieve a sense of belonging after incarceration and noted the ways CLSI-related stigma and aging-specific barriers (e.g., mobility limitations, financial constraints, and mental deterioration) dampened women’s willingness and ability to access health services. Latham-Mintus et al.’s 5 intersectional analysis of health in community-dwelling older people with and without a history of incarceration delineated disparities in physical, functional, and mental health that disproportionately affected older women and particularly older Black women. In discussion, Latham-Mintus et al. acknowledged how incarceration could itself produce trauma responses (i.e., posttraumatic prison disorder) in women, posing barriers to health services use and social engagement post-incarceration and intensifying or creating health hurdles. In a similar analysis that focused on women only, Emerson et al. 3 identified relationships between incarceration and frailty, multimorbidity, polypharmacy, mortality, and depression in older community-dwelling women with previous incarceration compared with a matched group with no previous incarceration. Most studies emphasized aging-related health issues in older women with past incarceration from a deficit orientation, though one source identified examples of benefit-finding in women who said they appreciated the strength they gained in living through tough life experiences. 27
Only one study in our sample focused on women’s experiences specifically during transition and reentry, though a number referred to the 12- to 24-month period after incarceration as one fraught with additional obstacles to health. In analyzing interviews with older women in Ottawa, Canada, who returned to the community after long prison sentences, their families, and service professionals who worked with the women, Shantz and Frigon 40 found the women struggled with undertreated, now-cascading physical conditions (e.g., chronic disease, mobility, chronic pain); employment barriers leading to frustrated self-sufficiency; and difficulties with social belonging, including finding safety in relationships and spaces and understanding roles. Shantz and Frigon noted that while such reentry challenges are many, “few solutions are apparent.” The authors pointed to ad hoc remedies, such as the development of collaborative, supportive, social networks by local care providers and individual instances of front-line service professionals who worked creatively within constrained systems to provide extra help or support. Other studies in our sample made passing reference to the importance of continuity of care during transition, 21 easier access to long-term care, 26 gender-responsive transitional services, 5 and finding ways to facilitate women’s ability to pay for health care during reentry. 21
Coping strategies, strengths, and resources
Older women with CLSI coped with threats to physical and mental health posed by incarceration in a variety of ways. In studies that focused on health during incarceration, researchers observed the health protective purpose, effect, or potential of friendships with other inmates and maintenance of ties with family outside35,41; development of family-like relationships with other women inside29,35; humanization of inanimate objects like books as friends 28 ; and engagement privately or with others in spiritual activities like prayer, religious services, and pastoral care. 22 Aday et al.’s interviews with women with life sentences centered on religious activity as a resource for older women in coping with increasing physical and functional health impairment, loss and grief, hopelessness, and anxiety about dying in prison. 22 In Hongo and and Valenti’s 29 description of an art therapy program for older women in prison, participants described how the small-group art activities provided catharsis, connection, and an outlet for creativity. Women learned while incarcerated how to perform or “prove” character and illness, so that when they sought care they would be believed. 21 Other coping strategies included retreat, self-isolation, denial,25,38,28 and overeating.36,41 Shantz and Frigon’s 40 interviews indicated that some older women coped with the deterioration of physical and mental health they experienced during imprisonment by self-isolating and self-medicating post-incarceration. James et al. 32 detailed how shutdowns during the first months of the COVID-19 pandemic complicated older women’s management especially of mental health by restricting social interaction, movement, space, and delivery of both group and individual mental health services.
Solutions to health challenges of older women with CLSI
The final common idea we found in the sources was solutions to health challenges faced by older women during or after incarceration. We identified three clusters: standards, staffing, and training; structure change; and system and societal change.
Standards, staffing, and training
Authors made recommendations that centered on the preparation, utilization, and practice of those who provide services during and after incarceration. Williams et al. 42 described a need for improved clinical guidelines in prisons, including more frequent assessment of older women’s functional ability. Emerson et al. 26 and Wennerstrom 41 also pointed to the problematic lack of uniformity and oversight in guidelines for medical services in carceral settings, while others described the need after incarceration for both more comprehensive 26 and more tailored 41 “wraparound” transition services to ensure older women’s continuity of care. Reviere and Young 38 suggested that carceral systems might employ more licensed social workers to address the shortage of mental health providers during incarceration. Authors of another study referred to programs in which younger people in prison are trained and employed to assist older people in prison with mobility and other functional impairments. 42 Several sources recommended improved training and credentialing of those who provide services to older women during incarceration23,26,39,41,42 and of professionals who serve formerly incarcerated women in the community.26,40 One source, drawing on interviews with prison staff, proposed changes to rules that restrict staff from showing empathy toward women during imprisonment to alleviate some of the sense of isolation older women experience. 23
Structure change
In four of the articles, authors made recommendations about the need for changes to built environments to improve how older women with CLSI are housed and how their health and safety are supported. These authors described the health-promoting advantages of dedicated or age-restricted housing units for older women, in which the risk of victimization by younger women might be better managed, noise and crowding reduced, and the physical environment and some health services made more accessible.23,38,40,42 Williams et al. 42 observed that even simple changes, like the installation of handrails in bathrooms and consideration of functional ability in the assignment of bunks, would be helpful, reducing to some extent the likelihood of falls. Also emphasized in Williams et al. 42 was the need for inspections and enforcement of environmental safety standards in carceral settings to ensure that the facilities themselves do not endanger health through exposure to sewage, mold, flooding, and air pollution.
System and society change
Potential system and societal reforms related to incarceration overall were proposed or described in a few studies.5,40,42 These concerned processes of decarceration and programs for compassionate or early release of older adults. James et al. pointed to how the COVID-19 pandemic resulted in an uptick of early releases in California but noted that older people made up but a small proportion of those releases. 32 Regarding decarceration, Latham-Mintus et al. emphasized the role research and especially outcomes data could play in spurring policy dialogue and shifting public views. 5 Robinson et al. underscored the need for more data-based study so that attention can focus on elements that need changing most. 39 Deaton et al.’s study sounded a warning about potential extension of the penal harm movement into the delivery of health care in carceral settings, such that poor quality or limited health care during incarceration comes to be regarded as itself a sanctioned means of punishing or deterring crime. 25
Discussion
In our scoping review of research focused on health in older women with CLSI over a 25-year period, we found 25 data-based publications. The overall scarcity of research suggests the continuing salience of the first of the shared emphasis areas we identified (i.e., acknowledging the unacknowledged). Most of the studies examined forms of physical, functional, mental, or social health in older women during incarceration (primarily prison) with fewer studies addressing the health status or needs of older women post-incarceration.
Health status
Among the most frequently reported cross-sectional health findings for older women in the articles was age-progressive chronic conditions like hypertension, cardiovascular disease, and arthritis (Table 2). Diabetes prevalence was reported in over a third of the studies, but surprisingly few sources addressed its management or complications. Also remarkable was the limited reporting on respiratory conditions such as chronic obstructive pulmonary disease, emphysema, or asthma. We know these are common health problems in samples with CLSI, who are known to smoke at three times the rate of the general population and may face environmental inequities over the long-term that result in disproportionate exposure to poor air quality.49,50 Although cancer was reported infrequently in the studies, the literature on cancer prevention and control in carceral settings has garnered support in recent years as an area of needed research focus.51,52 The omission of cancer in our sample is notable since many of the social drivers of disparity in breast and cervical cancer deaths (e.g., poverty, racial discrimination, inadequate health insurance, environmental exposure to toxicants)52–54 are also seen in women with CLSI. Aside from COVID-19, infectious disease was almost never assessed in studies focused on older women. Our sample included no studies that centered on older women’s prevention, transmission, or management of HIV, hepatitis B or C, or tuberculosis—all known to occur at higher rates in female populations with CLSI. Only two studies reported on dental or oral health,26,41 an underappreciated contributor to overall health in older adults, with links both to cardiovascular disease 55 and cognitive decline and dementia, 56 as well as implications for both functional (i.e., nutritional) health and social well-being. Among the other gaps we observed was a lack of attention, comparatively or longitudinally, to the pace or relative onset of aging-related conditions in or across groups of women, leaving open questions of whether, how, and how much the oft-cited phenomenon of aging acceleration in men occurs in women with CLSI.7,57
Of special note were findings on women’s functional ability, which covers a broad swath of capabilities that play a role in older adults’ ability to self-manage their physical and mental health, take part in basic or independent activities of daily living, and interact socially. The “prison activities of daily living (PADLs)” described in Williams et al. are a group of activities that people perform routinely while incarcerated. 42 They are also activities that older adults with decreased functional ability struggle to perform, for example, getting down on the floor for alarms, hearing orders from staff, standing for head count, walking to the dining hall, getting up on a top bunk, and climbing stairs. PADLs have been examined in research and government reports on aging while incarcerated,58–60 though, again—aside from the studies by Williams et al. and Aday et al. in our sample—not with a focus on older women.
Other conditions that intertwine with functional health—incontinence, falls, chronic pain, number of daily medications, and cognitive status—were notably omitted in most of the studies. None collected information on women’s cognitive status or memory, though higher prevalences of dementia and/or cognitive impairment have been documented among men in prison.61–63 Vision and/or hearing was included in only about a third of the sources in our sample in which data from surveys or medical records were analyzed. Falls were rarely mentioned. In data from the Third National Health and Nutrition Examination Survey (NHANES III; n = 1295), Karvonen-Gutierrez et al. found recurrent midlife falls to be associated with a four-fold increase in death within 10 years in women (but not men). 64 In general, a more comprehensive account of functional health in older women with CLSI would be useful, given the biopsychosocial wear-and-tear of stress related to CLSI, its likely effects on functional ability, and the potential of findings to inform clinical practice and intervention development.
Mental health and social well-being were other areas of emphasis in the articles. Depression was the most frequently reported mental health condition, followed by anxiety. Other mental and behavioral health conditions were surprisingly much less addressed, including trauma-related disorders and substance use disorder, both of which continue to occur in and influence the health of older adults.65,66 The literature demonstrates that people who are incarcerated report trauma-related events over the life course in high percentages.67–69 Only a few sources in our sample included measures for either trauma exposures or trauma symptoms and none asked older women if they had ever been diagnosed with posttraumatic stress disorder (PTSD)—though PTSD was mentioned in discussions as a precursor and amplifier of health risk during incarceration and as a potential response to the experience of incarceration itself in the form of post-incarceration trauma.70,71
Measures of social well-being were slightly better represented, with about half the studies describing or reporting evidence of older women’s social engagement, including meaningful connections with family and friends during and after incarceration. An emphasis on social connections is consistent with theory about women’s relational modes of coping with CLSI and the amplified sense of isolation that many women with CLSI experience when separated from family during incarceration.72,73 Though rarely studied in older women with CLSI (an exception being a study by Krabill and Aday, not reviewed here 74 ), relationality and social engagement have been a touchstone for health intervention design for all-ages women with CLSI, including therapeutic community and gender-responsive approaches.75,76 Psychosocial resilience in older women with CLSI was also an uncommon focus in the reviewed articles, though resilience has been a subject of research with older men during imprisonment 77 and features in one of the few researched interventions for incarcerated older adult men (i.e., True Grit). 78 While we found no intervention studies designed for older women during incarceration, the program evaluation by Hongo and Valenti. described a resilience-shaped pattern for older women’s coping and emphasized the program’s positive effects on women’s sense of belonging and connectedness. 29 Social support, engagement, and interaction in general are important for health in older people and can be protective against both mental and physical illness but may be more difficult for older people with a history of incarceration due to stigma and other social factors.79,80
Health services access and policy
For women with CLSI, leaving incarceration can mean a disrupted course of care for chronic and other conditions. A noticeable gap in the literature was research to examine the harms of inadequate transitions of care, including to long-term care. We found no research on the costs of delayed health care because of frustration or fear of mistreatment resulting from experiences in carceral health systems, though several authors noted the phenomenon.33,38,40 Case management, gender responsivity, and multi-pronged transition programs, both clinic- and residence-based, and especially programs with peer components, have been effective in bridging health services from prison-to-community—where they are available. 81 But even programs like Transitions Care Network, among the best studied and apparently successful of these models, are not available everywhere, 82 leaving older women in many communities to find case management and coordinate continuity of care as best they can.
Older women after incarceration in the United States face additional challenges related to paying for health care. In the United States, due to the so-called “inmate exclusion,” the Centers for Medicare and Medicaid Services (CMS) suspends all Medicare and Medicaid reimbursements during incarceration, except for some off-site hospitalizations. 83 On returning to the community, many older people face a bewildering reactivation or reapplication process that can take months. Developing state-based programs to assist people with establishing or reestablishing federal health payments in the months prior to leaving incarceration has been the purpose of the CMS-sponsored 1115 Waiver demonstration program. 84 Nineteen states have approved 1115 Waiver demonstration projects. 84 People receiving Social Security payments face similar challenges, except that the Social Security Administration terminates benefits when a person is incarcerated for 12 months or more, necessitating a new application. Though central to health and frequently a topic of reviews and commentaries, payment policies have not been a focus of research concerning older women’s incarceration. In Canada and the United Kingdom, where national health service coverage extends to people before, during, and after incarceration, health services may still be inadequate to meet older women’s needs while incarcerated and tend, like the United States, to be fragmented post-incarceration.39,40,85,86 In our review, studies conducted in Pakistan, 34 the Philippines, 37 and Switzerland 28 did not address specific national policies or regulatory environments, although authors highlighted a need for prison-level policies to meet aging-related health needs in gender-responsive ways.
Implications
The findings in this review imply need for more research reaching a broader audience. Latham-Mintus et al.’s 5 observation about the power of data stressed how systematic documentation is required to capture the attention of the public and motivate legislators and regulatory bodies. Health data points on older women can be gleaned from studies and reports—some of them excellent and frequently cited. But there remains scant research about older women with CLSI and their health. Focused attention on the experience of women’s aging during and after incarceration is needed to normalize and elevate the idea of health equity for the group and provide an empirical basis for better policies, improved clinical practice, and more responsive programming.
Finally, studies focused on health-related topics concerning older women with CLSI are mainly descriptive and exploratory, ranging across a number of topics—from functional health to death anxiety, to obesity, to menopause, to coping through art. The use of theoretical frameworks in these studies, as a basis for explanation or to organize description, was also varied and, in about half the studies, absent. To move the field forward, some higher level coherence or agreement in theoretical orientation, around, for example, socioecological or biopsychosocial perspectives, would be helpful if only to establish basic assumptions that would help even disparate studies in a fragmented field respond to and build on one another. The pathways, life course, and standpoint perspectives we identified in several studies fall roughly in this realm. It is possible that such confluences will develop organically with increased attention, additional studies, and more interventional work.
Limitations
Limitations of this scoping review include potential selection bias, since our eligibility criteria called for a fair amount of subjective discernment in determining what constituted a “focus on” women. There are dozens of publications that report health-related results for both older men and women, but most refer to samples that are 90% or more male. We set out to learn what research has been done that focused on women, so we strove to include only studies in which older women’s health and experiences were central to the purpose and analysis of the work. We initially searched from 1980, but as the counts were negligible until 2000, we selected 2000 as our start date (Supplemental Material). Even so, it seems improbable that so few studies have been published. A few sources were left out of the review because, while they included sizable numbers of women and older adults, data were compared by sex or by age but not both together. This was the case with Binswanger et al.’s landmark analysis comparing the health of men and women in jail and prison with a large community-dwelling sample from a national dataset that did not break out results by age and sex together. 87 We also struggled with studies like Krabill and Aday’s 74 sociological examination of women’s social life in prison, a topic with obvious relevance to health but one we felt was well-represented by the other articles included from that team. For a scoping review, we might have focused over-selectively on data-based publications. Doing so meant we left out discussion pieces and editorials that have provided those of us working in the field with much-needed clarifying and foundation-building pointers. We also only reviewed articles available in English. To minimize the chances that we overlooked studies or failed to capture the range of relevant work, we engaged multiple researchers, conducted multiple rounds of searching and review, consulted with a reference librarian, mined our own and our colleagues’ collected references, and obtained critical feedback on the manuscript from a long-time researcher in women’s health and incarceration and from a community contact who has both lived experience of incarceration and professional experience assisting women after incarceration.
Lastly, we were conscious of the need to account for gender diversity in our search and selection of articles and purposefully set out to include studies that focused on people who identify as gender non-conforming or non-binary. While we identified studies about non-binary people with CLSI, we did not identify any focusing on older adults. We are mindful that gender diverse people with CLSI will have distinctive intersectional experiences that bear on their health in aging. We are also aware of the need to document their experiences and preferences to guide responsive, relevant approaches to support their healthy aging.
Conclusion
Despite the growing number of both older adults and women who enter and leave U.S. jails and prisons, research focused on older women with CLSI is rare. To better understand what is known about older women’s health, we conducted a scoping review of the existing literature, 2000–2025. We found limited research on the health needs of older women with CLSI while incarcerated or in the community, and we found almost none that was interventional. Common thematic emphases in the literature included older women’s physical, mental, and social health needs; sociodemographic and other predictors or risks that precede and may be amplified by incarceration; resources older women have for coping with health challenges; and recommendations to reduce barriers to older women’s health during and after incarceration.
Supplemental Material
sj-pdf-1-whe-10.1177_17455057251392754 – Supplemental material for A scoping review of research to address older women’s health during and after incarceration
Supplemental material, sj-pdf-1-whe-10.1177_17455057251392754 for A scoping review of research to address older women’s health during and after incarceration by Amanda Thimmesch, Camila Aponte, Kathryn J. Krueger, Andrea K. Knittel and Amanda Emerson in Women's Health
Footnotes
Acknowledgements
We owe many thanks to Ms. Mary Taylor of 3 Quarters of the Way Done and Dr. Patricia J. Kelly for their critical feedback on the manuscript; Julie Randolph, RN, KUMC PhD student, for contributions on an early version of the work; and the mentors on the KL2 project of which this review was a part: Drs. Megha Ramaswamy, Lisa Saldaña, Brie Williams, and Nick Zaller.
Ethical considerations
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Author contributions
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the CTSA grant from NCATS awarded to the Frontiers Clinical and Translational Science Institute (KL2TR002367).
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data availability statement
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Supplemental material
Supplemental material for this article is available online.
References
Supplementary Material
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