"Because I Was a Criminal and Drug Addict.": Experiences of Anti-Black Gendered Racism and Reproductive Injustice Among Black Pregnant and Postpartum Women with a Substance Use Disorder and Incarceration and Family Policing Histories.

Racism pervades the US criminal legal and family policing systems, particularly impacting cases involving women with a history of a substance use disorder (SUD). Laws criminalizing SUD during pregnancy disproportionately harm Black women, as do family policing policies around family separation. Discrimination within intersecting systems may deter Black pregnant women with a SUD from seeking evidence-based pregnancy and substance use care. This convergent parallel mixed-methods study aimed to illuminate how systemic oppression influenced the lived experiences of Black mothers with a SUD, facing dual involvement in the criminal legal and family policing systems. Using convenience and snowball sampling techniques, we recruited 15 Black mothers who were incarcerated, used substances while pregnant, and had a history with family policing systems. We conducted semi-structured interviews and developed and distributed a scale questionnaire to describe participants' experiences navigating overlapping systems of surveillance and control. Drawing on models of systemic anti-Black racism and sexism and reproductive justice, we assessed participants' experiences of racism and gender-based violence within these oppressive systems. Participants described how intersecting systems of surveillance and control impeded their prenatal care, recovery, and abilities to parent their children in gender and racially specific ways. Although they mostly detailed experiences of interpersonal discriminatory treatment, particularly from custody staff while incarcerated and pregnant, participants highlighted instances of systemic anti-Black gendered racism and obstetric racism while accessing prenatal care and substance use treatment in carceral and community settings. Their narratives emphasize the need for action to measure and address the upstream macro-level systems perpetuating inequities.

Allocating health care resources in jails and prisons during COVID-19: a qualitative study of carceral decision-makers.

COVID-19 created acute demands on health resources in jails and prisons, burdening health care providers and straining capacity. However, little is known about how carceral decision-makers balanced the allocation of scarce resources to optimize access to and quality of care for incarcerated individuals. This study analyzes a national sample of semi-structured interviews with health care and custody officials (n = 32) with decision-making authority in 1 or more carceral facilities during the COVID-19 pandemic. Interviews took place between May and October 2021. We coded transcripts using a directed content analysis approach and analyzed data for emergent themes. Participants reported that facilities distributed personal protective equipment to staff before incarcerated populations due to staff's unique role as potential vectors of COVID-19. The use of testing reflected not only an initial imperative to preserve limited supplies but also more complex decision-making about the value of test results to facility operations. Participants also emphasized the difficulties caused by limited physical space, insufficient staff, and stress from modifying job roles. The rapid onset of COVID-19 confronted decision-makers with unprecedented resource allocation decisions, often with life-or-death consequences. Planning for future resource allocation decisions now may promote more equitable decisions when confronted with a future pandemic event.

Mental health, chronic and infectious conditions among pregnant persons in US state prisons and local jails 2016-2017.

BACKGROUND: Pregnant individuals in incarcerated settings have unique healthcare needs. Rates of mental health, infectious diseases, and chronic disease are higher among nonpregnant incarcerated women compared with those who are not, but the prevalence of these conditions among pregnant people in custody has not been documented. OBJECTIVES: The objective of this study is to describe the prevalence of metabolic, infectious, and mental health conditions in pregnant people to identify the medical needs of high-risk pregnancies in US state prisons and local jails. STUDY DESIGN: This was a prospective epidemiologic surveillance of a convenience sample of state prisons (n = 20) and local jails (n = 3). METHODS: We used purposive and snowball sampling to recruit a national sample of prisons and jails of a range of sizes and geographies. Reporters submitted to our study database monthly data on selected pregnancy comorbidities for 6 months between 2016 and 2017. Screening, diagnosis, and tracking of these conditions are derived from each facility's medical record and health care delivery systems. RESULTS: Of the 445 newly admitted pregnant people in prisons and 243 in jails, the most prevalent conditions were mental health conditions and hepatitis C. Specifically, 34.1% (n = 152) in prison and 23.5% (n = 57) in jail had a substance use disorder, and 27.4% (n = 122) of those in prison and 17.7% (n = 43) in jail had a psychiatric diagnosis. Finally, 20.2% (n = 91) in prison and 6.6% (n = 16) in jail had hepatitis C. CONCLUSIONS: This study demonstrates that chronic medical and mental health conditions are prevalent among pregnant people in US prisons and jails. However, significant variability in the reported number of cases of these conditions from state to state and between facility types implies a lack of or inadequate screening practices. These data indicate the need for comprehensive screening and appropriate care for the complex needs of pregnant incarcerated people.

OBJECTIVES: The objective of this study is to describe the prevalence of these conditions in pregnant people to identify the medical needs of high-risk pregnancies in US state prisons and local jails. STUDY DESIGN: The study involved ongoing systematic data collection, analysis and interpretation of pregnancy data from a convenience sample of state prisons (n = 20) and local jails (n = 3). METHODS: We intentionally recruited a national sample of prisons and jails of a range of sizes and geographies that house pregnant individuals. Some study facilities were referred from others. Reporters submitted to our study database monthly data on selected pregnancy comorbidities for 6 months between 2016 and 2017. Screening, diagnosis, and tracking of these conditions derived from each facility's medical record and health care delivery systems. RESULTS: Of the 445 newly admitted pregnant people in prisons and 243 in jails, the most prevalent conditions were mental health conditions and hepatitis C. Specifically, 34.1% (n = 152) in prison and 23.5% (n = 57) in jail had a substance use disorder and 27.4% (n = 122) of those in prison and 17.7% (n = 43) in jail had a psychiatric diagnosis. Finally, 20.2% (n = 91) in prison and 6.6% (n = 16) in jail had hepatitisc. CONCLUSIONS: This study demonstrates that chronic medical and mental health conditions are prevalent among pregnant people in US prisons and jails. However, significant variability in the reported number of cases of these conditions from state to state and between facility types implies a lack of or inadequate screening practices. These data indicate the need for comprehensive screening and appropriate care for the complex needs of pregnant incarcerated people.

Health care conditions among pregnant persons in US state prisons and local jails 2016­2017Background: Pregnant individuals in incarcerated settings have unique health care needs. Rates of mental health, infectious diseases, and chronic disease are higher among nonpregnant incarcerated women compared with those who are not, but the prevalence of these conditions among pregnant people in custody has not been documented.

"It's different than a doctor saying 'You're making the right choice'": A qualitative study of chaplains' experience caring for patients undergoing abortion in Washington DC, Maryland, and Virginia.

OBJECTIVES: Health care chaplains are faith providers with theological education, pastoral experience, and clinical training who provide spiritual care to patients, their families, and medical staff. This study sought to characterize chaplains' experiences providing spiritual care for patients experiencing abortion and pregnancy loss and to explore how chaplains gain competency and comfort in providing pastoral care for this patient population. STUDY DESIGN: Researchers conducted in-depth, semistructured, qualitative interviews with currently-practicing chaplains recruited via convenience sampling in the Washington DC, Maryland, and Virginia region. We analyzed interviews using directed content analysis and coded using both inductive and deductive coding. RESULTS: We interviewed 13 chaplains. The majority were Protestant and identified as Democrats. Participants often personally struggled with the acceptability of abortion but emphasized the importance of spiritual care for this patient population. They recognized that religious stigma regarding abortion prevented referrals to chaplaincy. Though desiring to contribute, chaplains reported little formal education in pregnancy support counseling. They relied on foundational pastoral care skills, like holding space, values clarification, connecting with patients' spirituality, words of comfort, ritualistic memorialization, and resource provision. All desired more training specific to abortion and pregnancy loss in chaplaincy education. CONCLUSIONS: Chaplains from varied faith backgrounds have a diverse set of skills to support patients experiencing abortion or pregnancy loss, but feel underutilized and lacking in formal training. Though not all patients require pastoral support, chaplains can be critical members of the care team, particularly for those patients experiencing spiritual distress. IMPLICATIONS: Chaplains have a paucity of training in supporting patients experiencing abortion and pregnancy loss. Chaplains want to be involved with patients experiencing abortion but feel excluded by both patients and practitioners. Standardization of pastoral care training is important to ensure adequate spiritual support for patients who desire such services.

Pandemic detention: life with COVID-19 behind bars in Maryland.

Background: People incarcerated during the COVID-19 pandemic face higher vulnerability to infection due to structural and social factors in carceral settings. Additionally, due to the higher prevalence of chronic health conditions among carceral populations, they are also at risk for more severe COVID-19 disease. This study was designed to explore the experiences of people incarcerated in prisons and jails in Maryland during the height of the pandemic. Methods: We conducted semi-structured phone interviews between January 2021 and April 2022 with ten individuals incarcerated in Maryland carceral facilities during the height of the U.S. COVID-19 pandemic and were subsequently released from prison or jail. We transcribed the interviews, coded them, and engaged in content analysis, an inductive analytical approach to developing themes and meaning from qualitative data. Results: Four themes emerged from participants' descriptions of their experiences: (1) distress from fear, vulnerability, and lack of knowledge about COVID-19 and how to protect themselves, (2) shortcomings of prison and jail administrators and other personnel through lack of transparency and arbitrary and punitive enforcement of COVID-19 protocols, (3) lack of access to programming and communication with others, and (4) absence of preparation for release and access to usual re-entry services. Conclusion: Participants responded that the prison and jails' response during the COVID-19 pandemic was ill-prepared, inconsistent, and without appropriate measures to mitigate restrictions on liberty and prepare them for release. The lack of information sharing amplified their sense of fear and vulnerability unique to their incarceration status. Study findings have several institutional implications, such as requiring carceral facilities to establish public health preparedness procedures and making plans publicly available.

Release, Reentry, and Reintegration During COVID-19: Perspectives of Individuals Recently Released from the Federal Bureau of Prisons.

Introduction: The COVID-19 pandemic had a large negative impact on people in U.S. prisons. Expedited releases from prison were one strategy used to decrease morbidity and mortality from COVID-19. However, little is known about the reentry experiences of those being rapidly released from custody early in the pandemic. Methods: We aimed to examine the perspectives of former residents in the Federal Bureau of Prisons (BOP) regarding release, reentry, and reintegration into their respective communities. We conducted semistructured interviews with 21 recently released individuals primarily recruited through legal aid organizations between September and October 2021. Subjects were incarcerated before and during the early surge in the COVID-19 pandemic. We coded transcripts thematically with domains developed a priori in which we revised iteratively and inductively based on the data. Results: Several major themes emerged. Participants reported that they needed to advocate for themselves to take advantage of the early release process. Compared with normal circumstances, they reported a lack of reentry planning and preparation before participants were released. Finally, experiences with reintegration varied but were often more challenging due to COVID-19. Discussion: Residents released during COVID-19 reported many challenges with reentry that could have been mitigated by support and guidance from the BOP. Reentry is a process that should begin prelease and continues postrelease to ensure individuals have adequate structural and social supports. Health Equity Implications: Inadequate reentry support has significant impacts on the health and well-being of recently released individuals and contributes to the broader context of achieving health equity for minitorized groups who are disproportionately overrepresented in prisons. Policy and practice reform is needed to address the time-sensitive, life-threatening challenges individuals face when transitioning from prison to community.

"I mean, I didn't really have a choice of anything:" How incarceration influences abortion decision-making and precludes access in the United States.

OBJECTIVE: To understand how the punitive, rights-limiting, and racially stratified environment of incarceration in the United States (US) shapes the abortion desires, access, and pregnancy experiences of pregnant women, transgender men, and gender non-binary individuals. METHODS: From May 2018-November 2020, we conducted semi-structured, qualitative interviews with pregnant women in prisons and jails in an abortion supportive and an abortion restrictive state. Interviews explored whether participants considered abortion for this pregnancy; attempted to obtain an abortion in custody; whether and how incarceration affected their thoughts about pregnancy, birth, parenting, and abortion; and options counseling and prenatal care experiences, or lack thereof, in custody. RESULTS: The conditions of incarceration deeply shaped our 39 participants' abortion and pregnancy decisions, with some experiencing pregnancy continuation as punishment. Four themes emerged: (1) medical providers' overt obstruction of desired abortions; (2) participants assuming that incarcerated women had no right to abortion; (3) carceral bureaucracy constraining abortion access; and (4) carceral conditions made women wish they had aborted. Themes were similar in supportive and restrictive states. CONCLUSIONS: Incarceration shaped participants' thoughts about pregnancy and their abilities to access abortion, consider whether abortion was an attainable option, and make pregnancy-related decisions. These subtle carceral control aspects presented more frequent barriers to abortion than overt logistical ones. The carceral environment played a more significant role than the state's overall abortion climate in shaping abortion experiences. Incarceration constrains and devalues reproductive wellbeing in punitive ways that are a microcosm of broader forces of reproductive control in US society.

Assessing provision of MOUD and obstetric care in U.S. jails: A content analysis of policies submitted by 59 jails.

AIMS AND BACKGROUND: Thousands of pregnant people with opioid use disorder (OUD) interface with the United States (US) carceral system annually. However, little is known about the consistency and breadth of medications for opioid use disorder (MOUD) for incarcerated pregnant people in jail, even at facilities that offer treatment; the goal of our study is to illuminate the current practices for OUD management in US jails. METHODS: We collected and analyzed 59 self-submitted jail policies related to OUD and/or pregnancy from a national, cross-sectional survey of reported MOUD practices for pregnant people in a geographically diverse sample of US jails. Policies were coded for MOUD access, provision, and scope, then compared to respondents' submitted survey responses. RESULTS: Of 59 policies, 42 (71%) mentioned OUD care during pregnancy. Among these 42 polices that mentioned OUD care during pregnancy, 41 (98%) allowed MOUD treatment, 24 (57%) expressed continuing pre-existing MOUD treatment that was started in the community pre-arrest, 17 (42%) initiated MOUD in custody, and only 2 (5%) mentioned providing MOUD continuation post-partum. Facilities varied in MOUD duration, provision logistics, and discontinuation policies. Only 11 (19%) policies were completely concordant with their survey response regarding MOUD provision in pregnancy. CONCLUSIONS: The conditions, criteria, and the comprehensiveness of MOUD provision and protocols for pregnant people in jail remain variable. The findings demonstrate the need to develop a universal comprehensive MOUD framework for incarcerated pregnant people to reduce the increased likelihood of death from opioid overdose upon release and in the peripartum period.

"It was like you were being literally punished for getting sick": formerly incarcerated people's perspectives on liberty restrictions during COVID-19.

BACKGROUND: COVID-19 has greatly impacted the health of incarcerated individuals in the US. The goal of this study was to examine perspectives of recently incarcerated individuals on greater restrictions on liberty to mitigate COVID-19 transmission. METHODS: We conducted semi-structured phone interviews from August through October 2021 with 21 people who had been incarcerated in Bureau of Prisons (BOP) facilities during the pandemic. Transcripts were coded and analyzed, using a thematic analysis approach. RESULTS: Many facilities implemented universal "lockdowns," with time out of the cell often limited to one hour per day, with participants reporting not being able to meet all essential needs such as showers and calling loved ones. Several study participants reported that repurposed spaces and tents created for quarantine and isolation provided "unlivable conditions." Participants reported receiving no medical attention while in isolation, and staff using spaces designated for disciplinary purposes (e.g., solitary housing units) for public health isolation purposes. This resulted in the conflation of isolation and discipline, which discouraged symptom reporting. Some participants felt guilty over potentially causing another lockdown by not reporting their symptoms. Programming was frequently stopped or curtailed and communication with the outside was limited. Some participants relayed that staff threatened to punish noncompliance with masking and testing. Liberty restrictions were purportedly rationalized by staff with the idea that incarcerated people should not expect freedoms, while those incarcerated blamed staff for bringing COVID-19 into the facility. CONCLUSIONS: Our results highlighted how actions by staff and administrators decreased the legitimacy of the facilities' COVID-19 response and were sometimes counterproductive. Legitimacy is key in building trust and obtaining cooperation with otherwise unpleasant but necessary restrictive measures. To prepare for future outbreaks facilities must consider the impact of liberty-restricting decisions on residents and build legitimacy for these decisions by communicating justifications to the extent possible.

COVID-19 vaccination hesitancy and uptake: Perspectives from people released from the Federal Bureau of Prisons.

People in United States (US) prisons and jails have been disproportionately impacted by the COVID-19 pandemic. This is due to challenges containing outbreaks in facilities and the high rates of health conditions that increase the risk of adverse outcomes. Vaccination is one strategy to disrupt COVID-19 transmission, but there are many factors impeding vaccination while in custody. We aimed to examine the perspectives of former residents in the Federal Bureau of Prisons (BOP) regarding COVID-19 vaccine hesitancy and acceptance. Between September-October 2021, we conducted semi-structured interviews with 21 recently released individuals who were incarcerated before and during COVID-19 and coded transcripts thematically. We assessed perceptions of the vaccine rollout and factors shaping vaccination uptake in custody and after release. The vaccine was available to seven participants in custody, of whom three were vaccinated. Interviewees had mixed attitudes about how vaccines were distributed, particularly with priority given to staff. Most were reluctant to get vaccinated in custody for varying reasons including observing staff declining to be vaccinated, lack of counseling to address specific questions about safety, and general lack of trust in the carceral system. By contrast, twelve got vaccinated post-release because of greater trust in community health care and stated they would not have done so while incarcerated. For residents in the BOP, COVID-19 vaccination was not simply a binary decision, instead they weighed the costs and benefits with most deciding against getting vaccinated. Institutions of incarceration must address these concerns to increase vaccine uptake as the pandemic continues.

Shackling and pregnancy care policies in US prisons and jails.

OBJECTIVES: The number of incarcerated women in the United States has risen exponentially. Many are of childbearing age with 3-4% being pregnant at intake. Despite the need for comprehensive pregnancy-related health care in prisons and jails, there is no oversight that requires adherence to the established standards. The objective of this study was to assess prison and jail pregnancy policies and practices with an emphasis on restraint use and compliance with anti-shackling legislation. METHODS: We conducted a survey of 22 state prisons and six jails, including the five largest jails, from 2016-2017 regarding pregnancy policies and practices including restraint use, prenatal care, delivery and birth, and other pregnancy accommodations. We compared reported restraint policies to state legislation at the time of the survey. RESULTS: Data indicate that pregnancy policies and services in prisons and jails vary and compliance inconsistencies with anti-shackling legislation exist. A third of the prisons and half of the jails did not have accredited health care services. All study facilities provided prenatal vitamins and most provided supplemental snacks. Most facilities stationed an officer inside the hospital room during labor and delivery, but nearly one-third of facilities did not require a female-identifying officer. CONCLUSIONS FOR PRACTICE: Limited oversight and standardization of carceral health care and accommodations for pregnant people lead to variability in prisons and jails. Prisons and jails should adopt and implement standards of care guidelines to ensure the safety and well-being of pregnant people who have unique healthcare needs. Incarcerated pregnant people should be viewed as expectant parents in need of comprehensive health care, rather than as criminals who forfeited their right to a safe, respectful, and humane childbirth.

COVID-19's Effect on Pregnancy Care for Incarcerated People.

Objective/background: Prisons and jails are high risk environments for COVID-19. Little is known about COVID-19's impact on pregnancy care for the tens of thousands of pregnant people who pass through these institutions each year. This study aimed to describe how COVID-19 has influenced prisons' and jails' pregnancy care services. Methods: We conducted a cross-sectional survey of a convenience sample of U.S. prisons and jails and report descriptive statistics. Results: We received 17 responses. Sites reported changes in prenatal care delivery, support programming, housing, and visitation. Most sites implemented changes in housing arrangements to quarantine individuals at-risk for COVID-19. Many sites increased their use of virtual technology to supplement for suspended in-person appointments, programming, and visitation. Conclusions: The impact of COVID-19 on pregnancy care delivery and support services for incarcerated pregnant people is variable. As the pandemic continues, research and policy should ensure that incarcerated pregnant people have access to full scope pregnancy care.

A Human Rights Framework for Advancing the Standard of Medical Care for Incarcerated People in the United States in the Time of COVID-19.

The COVID-19 pandemic has underscored the lack of resources and oversight that hinders medical care for incarcerated people in the United States. The US Supreme Court has held that "deliberate indifference" to "serious medical needs" violates the Constitution. But this legal standard does not assure the consistent provision of health care services. This leads the United States to fall behind European nations that define universal standards of care grounded in principles of human rights and the ideal of equivalence that incarcerated and non-incarcerated people are entitled to the same health care. In this paper, we review a diverse legal and policy literature and undertake a conceptual analysis of policy issues related to the standard of care in correctional health; we then describe a framework for moving incrementally closer toward a universal standard. The expansion of Medicaid funding and benefits to corrections facilities, alongside a system of comprehensive and enforceable external oversight, would meaningfully raise the standard of care. Although these changes on their own will not resolve all of the thorny health problems posed by mass incarceration, they present a tangible opportunity to move closer to the human rights ideal.

Female permanent contraception policies and occurrence at a sample of U.S. prisons and jails.

OBJECTIVE(S): Incarcerated individuals have an unmet need for contraception, yet have also been subject to coercive permanent contraception practices. Data do not exist on prison and jail policies around access to permanent contraception or how often it occurs among women in custody. We sought to describe permanent and reversible contraception policies at U.S carceral institutions and the frequency of these procedures. STUDY DESIGN: We surveyed a convenience sample of 22 state prison systems and 6 county jails from 2016 to 2017 about female permanent contraception and reversible contraception policies. In addition, 10 prisons and 4 jails reported 6 months of monthly data on the number of postpartum permanent contraception procedures performed on women who gave birth in custody. We analyzed results for descriptive statistics. RESULTS: Eleven prisons (50%) and 5 jails (83%) permitted female permanent contraception; 7 of these prisons and 3 of these jails allowing permanent contraception did not have a written policy about it. Six prisons and no jails provided access to permanent but not reversible contraception. Over 6 months, 3 women from 2 prisons and 4 women at 2 jails received postpartum permanent contraception. CONCLUSION(S): The majority of prisons and jails in our study allowed incarcerated women to have permanent contraception in custody, often without formalized policies in place. Postpartum permanent contraception occurred during the study period. Given the inherent lack of autonomy of incarceration and history of sterilization abuses in this marginalized group, policy-makers should advance policies that avoid coercive permanent contraception and increase access to reversible contraception in carceral settings. IMPLICATIONS: Many carceral institutions permit women to undergo permanent contraception but provide no access to reversible contraception; this practice raises concern for compromised autonomy and further reproductive marginalization of a group with limited access to quality reproductive health care.

Contraception Policies in U.S. Jails, Prisons, and Juvenile Detention Systems: A National Survey.

Contraception is an important health care service for incarcerated women, yet its availability in U.S. prisons, jails, and juvenile detention systems is unknown. We surveyed 6 jails, 22 state prisons, and 3 juvenile detention systems (N = 31 sites) on their contraception policies in 2016. Twenty (65%) sites had formal written contraception policies. All sites allowed people to continue a preincarceration contraceptive method with restrictions on the type of contraception and reason for use. Two sites (6%) did not allow continuation of oral contraceptive pills, 3 sites (10%) did not allow continuation of contraceptive injection, 21 sites (68%) did not allow continuation of contraceptive ring, and 23 sites (74%) did not allow continuation of contraceptive patch. Twenty-eight (90%) sites allowed people to initiate a contraceptive method in custody. Contraception policies in incarceration settings in the United States are varied and may restrict women's ability to continue or initiate the contraception of their choice.

Health care and social justice implications of incarceration for pregnant people who use drugs.

The experiences of and care for pregnant, incarcerated people with substance use disorders represent a convergence of numerous clinical, historical, racialized, legal, and gendered factors. Understanding how these forces shape how they became enmeshed in the criminal legal system as well as the context of the care they do or do not receive while in custody is essential for promoting equitable maternal health care. In this review, we describe the prevalence of SUD among pregnant people behind bars, the health care landscape of incarceration, access to treatment for opioid use disorder for incarcerated pregnant and postpartum people, and nuances of providing such treatment in an inherently coercive setting. Throughout, we highlight the ways that the child welfare system and mass incarceration in the U.S. have had a unique and discriminatory impact on pregnant and parenting people, and have done so in distinctly racialized ways. Situating the clinical care of incarcerated pregnant people who use drugs in this context sheds light on fundamental social justice and health care intersections.

Care for Incarcerated Patients Hospitalized with COVID-19.

The COVID-19 pandemic has reshaped health care delivery for all patients but has distinctly affected the most marginalized people in society. Incarcerated patients are both more likely to be infected and more likely to die from COVID-19. There is a paucity of guidance for the care of incarcerated patients hospitalized with COVID-19. This article will discuss how patient privacy, adequate communication, and advance care planning are rights that incarcerated patients may not experience during this pandemic. We highlight the role of compassionate release and note how COVID-19 may affect this prospect. A number of pragmatic recommendations are made to attenuate the discrepancy in hospital care experienced by those admitted from prisons and jails. Physicians must be familiar with the relevant hospital policies, be prepared to adapt their practices in order to overcome barriers to care, such as continuous shackling, and advocate to change these policies when they conflict with patient care. Stigma, isolation, and concerns over staff safety are shared experiences for COVID-19 and incarcerated patients, but incarcerated patients have been experiencing this treatment long before the current pandemic. It is crucial that the internist demand the equitable care that we seek for all our patients.

Rethinking "Elective" Procedures for Women's Reproduction during Covid-19.

Common hospital and surgical center responses to the Covid-19 pandemic included curtailing "elective" procedures, which are typically determined based on implications for physical health and survival. However, in the focus solely on physical health and survival, procedures whose main benefits advance components of well-being beyond health, including self-determination, personal security, economic stability, equal respect, and creation of meaningful social relationships, have been disproportionately deprioritized. We describe how female reproduction-related procedures, including abortion, surgical sterilization, reversible contraception devices and in vitro fertilization, have been broadly categorized as "elective," a designation that fails to capture the value of these procedures or their impact on women's overall well-being. We argue that corresponding restrictions and delays of these procedures are problematically reflective of underlying structural views that marginalize women's rights and interests and therefore threaten to propagate gender injustice during the pandemic and beyond. Finally, we propose a framework for triaging reproduction-related procedures during Covid-19 that is more individualized, accounts for their significance for comprehensive well-being, and can be used to inform resumption of operations as well as subsequent restriction phases.

Testing for sexually transmitted infections at intrauterine device insertion: an evidence-based approach.

This article reviews evidence to guide safe and cost-effective testing for asymptomatic Neisseria gonorrhea and Chlamydia trachomatis infection before inserting intrauterine devices (IUDs). All women should be screened with a history and pelvic examination before IUD insertion, but only high-risk women need a laboratory test; this includes women aged 25 years or younger with no test within the last year, and women with additional behavioral risk factors. If testing is indicated, it should be done on the same day as insertion not a separate visit. Women with positive test results should be treated as soon as results are available.