Men in prison: the needs of the neglected majority

Men and boys make up more than 90% of the global prison population [1]. This fact, which is as accurate now as it has been historically, has led to prison design and regimes, both healthcare and disciplinary, being tailored to their needs at the expense of women and children in prison. However, we must not forget the growing recognition of gender specific issues for imprisoned men, e.g., toxic masculinity, hidden trauma (sexual and physical) histories, and the gender imbalance evident in some psychiatric disorders such as antisocial personality disorder (ASPD). We argue that, with the right design and resources, prisons can serve as a therapeutic environment in which such issues can be addressed. Furthermore, there are compelling reasons to actively research these areas to provide an evidence base for generalised interventions. The articles in this special issue accomplish exactly that.

The numbers of men in prison make this a matter of some urgency. The prison population continues to rise throughout the world [2], meaning that increasing numbers of men are experiencing incarceration. Eleven and a half million people are in prison worldwide, of whom 10.5 million are men. In the United Kingdom, which includes the jurisdiction of England and Wales in which our work is based, the male prison population has also continued to increase (by 3% since 2019) while the female prison population has decreased by 13% during the same period [3].

People in prison experience higher rates of mental health and substance misuse disorders, are more likely to engage in self-harm or suicide, more likely to meet the diagnostic criteria for a neurodevelopmental disorder or intellectual disability, and more likely to have a history of traumatic brain injury than the general population [4, 5, 6, 7, 8, 9, 10]. A recent umbrella review of mental and physical disorders suggested that mental disorders were twice as common in global prison populations as in the general population [8]. The same study found significantly higher rates of ASPD amongst men in prison, whilst rates of other disorders were broadly the same or higher in women. However, the complex comorbid triad of severe mental illnesses, personality disorders and substance misuse has a higher prevalence among men in prison in comparison to women [4]. Many men in prison have experienced significant adversity, trauma and exposure to numerous adverse childhood experiences [11, 12]. This has been linked to increasing risk of incarceration and of experiencing a range of mental health difficulties [13]. The scale of prison specific rates of disorders, combined with the gender imbalances in prison populations, underlines the level of demand for prison health care services for men.

Prisons across the world have vastly different regimes, philosophies and circumstances and, therefore, provide very different experiences of incarceration. These vary between supportive, rehabilitative, and progression-focused services and punitive, cruel, and degrading experiences. The challenges within prisons differ significantly across jurisdictions but often include varying degrees of overcrowding, detention without trial, poor environmental conditions, segregation, violence, gang affiliations and cultures, coercion, bullying, debt as a result of illicit economies, use of drugs and alcohol of untested provenance and in dangerous forms, corruption, inappropriate placement in prison of mentally ill people, restricted access to activity, education, work, and mental and physical healthcare, and staffing and resourcing limitations impacting on delivery of planned regime [14]. Often, the experience of prison can be traumatising for both staff and prisoners [15] and, unsurprisingly, can precipitate or exacerbate mental health difficulties [16].

However, prison can offer the possibility of health gain [8, 17]. For example, those with alcohol addictions may show positive improvements following detoxification, and subsequent treatment, in prison [18]. Health gain in prison is not only intrinsically beneficial but men who have better mental health in prison and post-release have lower rates of recidivism [19]. Of note, mental illness increases the likelihood of recidivism amongst men more than women [20]. This highlights the importance of working to improve the mental health of men in prison for wider society; a reduction in reoffending leading to reduced economic and social burdens of crime.

The assumption that evidence-based interventions from community settings can be effectively transposed into prison systems has been challenged [21, 22]. The evidence base around specific psychological interventions within the prison population has been limited [23] but it is now growing. Systematic reviews demonstrate promising results across varied mental health difficulties and treatment modalities [24, 25, 26, 27]. There is increasing confidence of positive change as a result of specific clinical interventions for individuals and groups, and from system wide changes such as adaptations for neurodiversity and improved support and training for staff, and to limit re-traumatisation [28, 29, 30]. However, without exception, these studies report concerns about methodological weaknesses and invite further research.

This special issue, focused on the challenges of identifying and addressing mental health difficulties and neurodiversity among men in prison, brings together a collection of work that highlights areas of promise, ongoing study, and potential investment. Many challenges impede the study of interventions in detained populations, including additional steps and approvals required to conduct research in prisons, limited clinician time and resource, and difficulties with participant engagement and follow up. These factors make the research published in this special edition an invaluable contribution to an underserved population, which can have impact on today’s society and future generations.

In this volume, McMinn and Colleagues describe how to take a trauma informed approach to healing trauma among young adult men in custody, highlighting the importance of collaboration in treatment planning [30]. They emphasise the need to provide staff with the appropriate training and support to work with the high degree of trauma seen among people in prison, and to offset the burn out and moral injury observed among staff who work in prisons. They usefully highlight some of the challenges inherent in the work and how they have attempted to mitigate these, concluding by stressing the value of adopting a holistic and system-wide approach to healing trauma for young men in custody.

Three articles in this special edition focus on the high rates of traumatic brain injury (TBI) amongst men in prison. A review by Johnston and Ricciardelli [31] highlights the potential behavioural consequences of a TBI, such as increased impulsivity and aggression, and the poor correctional outcomes that come from trying to manage these behaviours in a rigid, prison system in which understanding, assessment and treatment of TBIs is lacking. They recommend the development of an in-depth understanding of the impact and interventions for people in prison with TBI internationally. An impetus to improve and shape services around these needs would enable staff to respond appropriately. Gorgens and colleagues report on the importance of providing screening and support for the adverse behavioural comorbidities of TBIs, such as substance misuse, mental illness, and attempted suicide [32]. They suggest that all men identified as having a history of brain injury should be provided with appropriately adapted behavioural health therapies, with a plea to evaluate the impact of these on cognitive functioning. Boglo and colleagues provide evidence of how brain injury rehabilitation services can result in decreased anxiety and depression amongst men in prison or on probation with TBI. This indicates one route of viable interventions for this population that impact on the behavioural health comorbidities detailed above [33].

Barriers to engagement are also of focus in this special issue. Ramesh and colleagues showed that men who adhere more to masculine norms are less likely to engage with psychological support [34]. Exploring this qualitatively, they usefully describe some of the ways in which masculinity is understood and “performed” within the prison setting, and where and how vulnerability can be permitted within the challenges of a busy prison. They note the importance of trusted peer support and suggest the need to change prison culture to combat barriers associated with masculinity.

The limited impact of an intervention to support men close to and after release is explored by Lennox and colleagues [35]. Despite overall poor engagement with a post-release intervention providing psychological and practical support, self-report of problems with alcohol at baseline was predictive of better engagement [35]. This exploration is important as it highlights an example of something clinicians would expect to be efficacious and yet was not found to be so. It further considers some of the reasons, including dosage of intervention which might help to explain the unexpected results.

This fascinating collection of studies shows repeatedly the myriad challenges affecting men in prison and the systems aiming to incarcerate, rehabilitate, and care for them. They have in common a concern not just with the individual men in prison but with changes to a challenging system, so that many more men can benefit. The adoption of wider screening, staff training, universal adaptations, and cultural changes addressing masculinity and trauma will be vital in identifying and addressing the mental health and neurodiversity needs of men in prison.

Availability of data and materials

No data was analysed for contribution to this editorial.

Author contributions

RK and AB—wrote the manuscript. SA and AF—reviewed and contributed to the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Not applicable.

Acknowledgment

We would like to thank everyone who contributed to this special edition.

Funding

This research received no external funding.

Conflict of interest

The authors declare no conflict of interest. Radha Kothari is serving as one of the Guest editors of this journal. We declare that Radha Kothari had no involvement in the peer review of this article and has no access to information regarding its peer review. Full responsibility for the editorial process for this article was delegated to XXY.