The number of women in America's jails and prisons has risen in recent decades but, compared to men, they still represent a sliver of the nation's prisoners.
But while women might remain a minority in correctional facilities, there is one area where they far surpass their male counterparts: rates of mental illness.
Rates of mental illness are already considered high among inmates nationally, a phenomenon that experts typically attribute to the long-term closure of state psychiatric hospitals and a severe shortage of community mental health resources like caseworkers and group homes. But, for reasons that are less clear, rates of mental illness are significantly higher among imprisoned women than imprisoned men.
In Pennsylvania, for instance, 22 percent of the 47,984 men in in its state prison system were categorized as having a mental illness on an average day last year according to the state Department of Corrections. By comparison, the rate was 67 percent - three times higher - among the 2,772 women in the system on an average day last year.
That gap is even wider among Pennsylvania state prisoners with serious mental illnesses, a term that categorizes severe and chronic conditions such as schizophrenia and bipolar disorder. While 7 percent of men in the system had a serious mental illness on an average day last year, the rate was 29 percent among its female inmates.
That disparity creates unique problems for a correctional system that, between its two women's prisons alone, houses more people with serious mental illnesses on an average day than Pennsylvania's two largest state mental hospitals.
It also raises a crucial question: Rates for mental illness and serious mental illness are not only significantly lower among each gender outside of prison, they're roughly the same. So, even with the reasons that experts typically cite for the high rates of mental illness among prisoners (the long-term closure of state hospitals and a lack of community mental health resources), why are those rates so much higher among Pennsylvania's imprisoned women than imprisoned men?
Trauma and the war on drugs
Rosemary Gido, professor emerita of criminology at Indiana University of Pennsylvania, said that disparity between rates of mental illness in Pennsylvania's state prison system doesn't surprise her.
"If you look at the last 20 years of research on women in prison, particularly in states like California, you will find high rates of mental illness among incarcerated women," she said.
So the question remains, why are so many mentally ill women imprisoned across the country?
Gido said she believes the answer can be traced back to the 1980s when the nation introduced 'tough on crime' policies, including mandatory minimum prison sentences and harsh prison sentences for use of illicit substances like crack cocaine.
Those new policies led to a surge of people into America's prisons: the inmate population exploded from 200,000 inmates in 1973 to 2.2 million in 2009.
Gido said that those newly incarcerated people, mostly drug offenders, included men and women but there was a key difference between them.
"In that net we cast, the women that we hauled in were more likely to be abused or to have suffered from trauma than men," Gido said.
Gido said that history of abuse and trauma, combined with changes to brain chemistry from heavy drug use, tended to translate to psychiatric problems like post traumatic stress disorder, bipolar disorder and major depressive disorder.
That was why, Gido said, rates of mental illness and serious mental illness are typically higher among incarcerated women than incarcerated men.
Researchers and correctional officials differ
But some disagree with Gido's explanation.
Henry Steadman, a sociologist and president of Policy Research Associates, a New York-based research firm that specializes in criminal justice issues, said that he was skeptical that the difference in mental illness rates was driven by trauma.
Steadman said he believed that trauma was just as prevalent among the men who were swept into the criminal justice system over the past 30 years as it has been among the women who have entered the system.
"Both men and women with serious drug problems have trauma and co-occurring disorders," Steadman said.
Steadman said that something more complex was happening that was leading to higher prevalence rates of mental illness among incarcerated women.
"The bottom line is that we do not know why," Steadman said. "Studies are needed on the life courses of women who are in jail to ascertain what the dynamics of their lives have been."
John Wetzel, the Secretary of Pennsylvania's Department of Corrections, is also skeptical of Gido's explanation that the disparity in mental illness rates is driven by a disparity in trauma.
Wetzel said that his department studied SCI Graterford, a men's prison near Philadelphia, that showed trauma prevalence rates of about 80 percent. He said generally studies showed a trauma prevalence rate of about 90 percent among women.
"That's not a significant difference that would explain the huge
percentage differences in rates of mental illness between male and female
prisoners," Wetzel said.
Wetzel said he didn't have a good explanation for the disparity, although he theorized that it might be because women and men reacted to those traumatic experiences in different ways.
Robert Marsh, director of the department's psychology office, leans toward that theory.
"Women may more readily say 'I'm depressed, I'm anxious about that,' " Marsh said. "Whereas probably with the guys you're going to hear, 'I'm drinking a whole lot, I'm using drugs, I'm acting out, I'm doing those kind of things.'"
Wetzel said those differences might increase the chance that female inmates reported symptoms of mental illness or their symptoms were more likely to be flagged by medical and correctional staff across the country.
"I think it's a truism that men underreport, black people underreport, so we know that there are groups that underreport globally," he said. "I think that applies here too."
In defense of the link between trauma
Arthur Lurigio, a professor of psychology at Loyola University Chicago, however, believes that Gido's explanation for the difference in mental illness rates between incarcerated men and women is reasonable.
Lurigio said that while it's true, as Steadman and Wetzel say, that trauma prevalence rates were also quite high among male prisoners, the difference lies in the kind of trauma that imprisoned women have experienced compared to imprisoned men.
"They are not going to be at the same levels as women because of the sexual abuse histories of women," Lurigio said.
Lurigio said research shows that men who are sentenced to prison are more like to be traumatized by witnessing violence, being a victim of violence or perpetrating violence between childhood and early adulthood.
In contrast, Lurigio said, researchers have found that incarcerated women tend to have experienced trauma in childhood, such as sexual abuse, that leads them to run away from home, drop out of school, and experiment with alcohol and drugs before they reach adolescence.
Once on that path, those girls are more likely to become addicted to drugs, which in turn may lead them to prostitution or other criminal activity to support their addiction. They are then likely to end up in positions where they may be further victimized.
As evidence of that, a 1999 report by the U.S. Bureau of Justice Statistics found that 57.2 percent of incarcerated women say they were abused before they entered state prison compared to only 16.1 percent of men. The same study found that 39 percent of incarcerated women reported they had experienced sexual abuse compared to only 5.8 percent of men.
Each of those traumatic experiences, Lurigio said, fundamentally changed their brains. He said that was a survival mechanism: experiences that trigger powerful negative emotions are imprinted on the brain to remind a person to avoid that experience in the future.
"If a rat eats poison the rat is never going to forget what food that was and it is going to avoid that food forever," Lurigio said. "And that sometimes happens to people."
But Lurigio said that it is fair to say, as Wetzel and Marsh do, that incarcerated women are more likely to report symptoms of trauma than incarcerated men, which likely does impact the disparity in prevalence rates to a degree.
"To talk about trauma is to show weakness and vulnerability," Lurigio said. "Women typically don't feel that way."
However, Lurigio added, the research showed the disparity between mental illness rates between genders in the correctional system was largely driven by the level and type of trauma experienced by women.
Challenges for correctional facilities
While there may be some disagreement over why so many incarcerated women have mental illnesses, there is consensus that it's a phenomenon that creates unique problems for correctional systems.
Gido, the professor emerita at Indiana University of Pennsylvania, said one of the biggest issues - be it Pennsylvania's state prison or any correctional system - is that owing to their histories of trauma and substance abuse, mentally ill women in prison can be particularly challenging to diagnose and treat.
"The treatment has to be two-sided to address the issue of mental illness and substance abuse and that's what makes the treatment of incarcerated mentally ill women so complex," she said.
According to data supplied by the Department of Corrections, 14.2 percent (6,467) of the prison's men had both drug abuse and mental illnesses (known as "co-occurring" disorders) on Nov 3. On that same day, the rate was 43.9 percent (1,198 women) among its female inmates.
Steadman, the president of Policy Research Associates, said another major problem for mentally ill women is that most prisons are typically designed to accommodate men rather than women.
"Their needs for safety are different and the kinds of assets that they need to be able to deal with their mental illness are different," he said.
For instance, Steadman said, given the high degree of sexual abuse that many incarcerated women have experienced, women's prisons need to provide private space. But privacy was typically in short supply in most prisons.
In addition, Steadman said, while mentally ill men tend to spurn group therapy in prison, such programming is far more popular among incarcerated women.
"But the space you would need to run those kind of groups is not available," Steadman said.
For his part, Lurigio, the professor of psychology at Loyola University Chicago, said that prisons must ensure that their mental health treatment programs are different for men and women.
Lurigio said that programs for incarcerated women should recognize the sexual and physical abuse women have often suffered. They also need to focus on teaching different life skills, like how incarcerated women can regain custody of their children.
"Regaining custody of their children is a primary focus for many incarcerated women," Lurigio said.
Are we doing enough?
There is concern among mental health and prison welfare advocates that those services for mentally ill women are sorely lacking in Pennsylvania's correctional system.
Ann Schwartzman, executive director for the Pennsylvania Prison Society, a group that advocates for the rights and welfare of inmates, said most correctional facilities still design the bulk of their programming for men.
"I think women end up in the system but with less options for programs and treatment or even support mechanisms that could really help," she said.
Schwartzman said that was particularly true for county prisons, which typically have small budgets and offer limited mental health treatment. But she said it was still true for large systems like Pennsylvania's state prison system.
Schwartzman said that while the Department of Corrections has improved mental health care across its facilities over the past few years, she still didn't think it was able to adequately meet the needs of its mentally ill inmates - both men and women - given the sheer number that were entering the system.
For instance, she said, between Pennsylvania's two state prisons for women - SCI Muncy and SCI Cambridge Springs - there were some promising programs. She pointed to the House of Hope, a 23-bed unit in SCI Muncy for women who have substance abuse issues and have suffered sexual abuse.
The problem, Schwartzman said, is that those and other programs were still too small to cater to the scale of need.
"It's tiny," Schwartzman said. "It can only handle a fraction of the women there, let alone a fraction of the women who really need some assistance."
Schwartzman said she would ultimately like to see more alternatives to prison so that women with mental illnesses can live and be treated in the community, close to their families.
But even more than that, Schwartzman said, she would like to see fewer mentally ill women ending up in prison to begin with.
"So maybe what we really need to do is look at prevention a lot more and not wait until they are in the system," she said.