Gynecologic conditions in the context of incarceration: A scoping review.

Meredith K. Wise: review conceptualization, search strategy design, abstract and full text review, data abstraction, data synthesis, manuscript drafting, final manuscript approval; Sahana Raghunathan: data abstraction, data synthesis, manuscript drafting, final manuscript approval; Sreya Upputuri: abstract and full text review, data abstraction, final manuscript approval; Elana Jaffe Brotkin: abstract and full text review, data abstraction, final manuscript approval; Tre D. Thorne: data abstraction; final manuscript approval; Jamie Conklin: search strategy design, search and database management, manuscript drafting, final manuscript approval; Andrea K. Knittel: review conceptualization, data abstraction, manuscript drafting, final manuscript approval, supervision.

This project was supported in part by funds from the National Institute of Child Health and Human Development (NICHD) (Knittel, K12HD103085, PI Neal‐Perry) and the University of Minnesota Department of Obstetrics and Gynecology (Wise).

This review follows the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) extension for scoping reviews. 17 We considered carceral facilities to include jails, prisons, remand facilities, and other settings detaining people below the age of majority. Studies were eligible for the review if they (i) discussed a benign or malignant gynecologic condition; (ii) included a population of people experiencing incarceration; and (iii) answered one or more of the four key questions identified prior to the search. These questions were modeled after aspects of the Aday and Anderson Framework for the Study of Access to Care and addressed prevalence, special management considerations, access to services, and patient experience. 18 All reference types were included except for review articles, commentaries, and book reviews. Gynecologic conditions included abnormal bleeding, menopause, pelvic pain, pelvic organ prolapse, urinary incontinence, cervical cancer screening, dysplasia, HPV, vaginitis, menstruation, and gynecologic malignancy. We also included general gynecologic care. We excluded several groups of studies. First, studies focused on care for sexually transmitted infections, pregnancy, contraception, and abortion in carceral contexts have been covered extensively in previous reviews. Second, we excluded studies reviewed in two prior systematic reviews on the prevalence of cervical dysplasia and HPV in populations experiencing incarceration. 7 , 16 Third, we excluded studies conducted in World War II incarceration camps to avoid inclusion of data known to have been collected in violation of human rights. Studies describing US immigration detention centers were also excluded as they represent a part of the civil legal system. 1 , 3 , 19 Finally, we excluded studies reporting on topics we did not consider benign or malignant gynecologic conditions: sexual behavior, forensics, sexual assault, domestic violence, intimate partner violence, and menstruation as a criminal defense or explanation of criminal behavior. Our research team, including a health sciences librarian, developed the search strategy. With a final search date of April 19, 2023, the librarian searched APA PsycInfo (EBSCO host ), CINAHL Plus with Full Text (EBSCO host ), Embase (Elsevier), PubMed ( https://pubmed.ncbi.nlm.nih.gov/ ), Scopus (Elsevier), and the ClinicalTrials.gov registry. The search strategy included a combination of keywords and subject headings for incarceration and benign or malignant gynecologic conditions with no language or date limits. The PubMed search is shown in Table  1 , and the complete, reproducible search strategy for all databases is available in the supplementary files. The research team also searched the cited references of all included studies. PubMed search strategy. References were exported to Endnote X9 (Philadelphia, Pennsylvania, USA), where duplicates were removed. The remaining studies were imported into Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia, available at www.covidence.org ) to organize and complete the review process. One researcher independently screened each reference title and abstract for eligibility. In the full text review stage, two reviewers independently screened each reference. Conflicts were resolved by consensus of the full research team or by the lead author. We created a data extraction template capturing the reference title, lead author, year of publication, country, gynecologic condition, and key question type (prevalence, management, access, or experience). One researcher extracted data from each study, with a second reviewer verifying the extracted data. We synthesized data according to the condition described and by the four key questions above pertaining to prevalence, management, access, or experience.

We identified 3417 citations that met our search criteria (Figure  1 ). After removing duplicates, we assessed 2150 titles and abstracts and 688 full texts for eligibility; 135 studies were included, corresponding to 137 reports. Included studies addressed all four of the key questions, and most addressed more than one. The studies came from 38 distinct countries, with the majority from the USA ( n =  49) Brazil ( n =  17) and the UK ( n =  13). There were a variety of study designs, with a majority being cross‐sectional descriptive studies, including many survey studies and chart review studies. There were also many studies that included qualitative methodologies. Some reports were published by governmental agencies and non‐governmental organizations. Because of the heterogeneity of data sources, the study design and methods were not always explicitly stated. The studies were conducted in a variety of settings, with a majority in prisons or jails, and a fair number in juvenile detention facilities. 6 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 122 , 123 , 124 , 125 , 126 , 127 , 128 , 129 , 130 , 131 , 132 , 133 , 134 , 135 , 136 , 137 , 138 , 139 , 140 , 141 , 142 , 143 , 144 , 145 , 146 , 147 , 148 , 149 , 150 , 151 , 152 , 153 , 154 , 155 PRISMA flow diagram demonstrating study selection process. Twenty‐three studies discussed the provision of routine or screening gynecologic care and exams, including 13 US studies, six from Brazil, two from the UK, and one each from Ghana and South Africa. Sixteen studies took place in prisons, three in jails, and four in other or a combination of facility types (Table  2 ). 46 , 63 , 65 , 67 , 69 , 72 , 76 , 77 , 79 , 80 , 81 , 95 , 97 , 101 , 107 , 117 , 118 , 127 , 136 , 138 , 145 , 153 , 155 Two studies discussed the prevalence of requesting a gynecology appointment, and six studies discussed the prevalence of receiving gynecologic exams in carceral facilities. 46 , 79 , 80 , 81 , 97 , 107 , 117 , 118 A study in a Brazilian correctional facility for adolescents found that 13 of 26 (50%) individuals received a gynecological cancer prevention exam, with eight (61.5%) of those being more than 1 year ago. 97 A study in a juvenile facility in the USA found that 87/133 (77%) of sexually active adolescents reported that they had a pelvic exam within the past year. 79 Ingram‐Fogel found that in a prison in the USA, 72.7% of health care appointments made by participants were for gynecologic conditions, and 39.6% of the participants had “chronic” gynecological conditions. 81 Several studies described rates of ongoing gynecologic care. Nicolau et al. found that 65 women (42%) received routine gynecologic care gynecologic care while incarcerated, ranging from every month to annually, and some were at inconsistent intervals. 117 , 118 De Araújo et al. found that in a Brazilian prison, 9% ( n =  115) of women had never had a gynecological exam. 46 Studies addressing gynecologic care and exams. Special considerations for routine gynecologic care discussed in seven studies included the need for gynecology‐focused educational initiatives and disparities in gynecologic care by socio‐demographic factors. 63 , 72 , 76 , 79 , 95 , 136 , 138 In one of these, Fink et al. described a curriculum developed around gynecologic care in a correctional center instructing on four areas: anatomy and physiology, vaginal ecology, the pelvic exam, and sexual health. 63 Gallagher et al. found that access varied in juvenile facilities and was significantly more likely in “all‐female, state‐owned, large populations and longer stay facilities” compared to short‐term, mixed gender, or locally‐ or privately‐operated facilities. 67 Access to services was discussed in 18 studies, and key themes discussed were difficulty requesting appointments, lack of appropriate gynecologic healthcare, and financial burden of obtaining gynecologic care during incarceration. 46 , 65 , 67 , 69 , 72 , 77 , 79 , 81 , 95 , 101 , 117 , 118 , 127 , 136 , 138 , 145 , 153 , 155 Incarceration affecting experiences of gynecologic care and exams was discussed in five studies. 69 , 72 , 77 , 95 , 136 For example, one US jail was reported to have inadequate health care for gynecologic conditions and unsanitary living conditions, such as residents being provided used underwear, causing them to develop gynecologic symptoms. 77 Consistent and reliable access to gynecological care and exams is generally difficult in carceral settings and is complicated by the availability of gynecologic appointments and providers, patients' trust in their providers, and many of the social determinants of health that also affect care outside of carceral settings. Thirty‐eight studies discussed normal menstruation during incarceration (Table  3 ). 29 , 31 , 35 , 36 , 39 , 40 , 41 , 46 , 51 , 52 , 64 , 69 , 71 , 72 , 73 , 77 , 82 , 95 , 97 , 99 , 102 , 112 , 114 , 115 , 120 , 126 , 127 , 129 , 134 , 136 , 137 , 148 , 149 , 150 , 151 , 152 , 155 , 156 The studies were performed in the USA ( n =  10), the UK ( n =  5), Brazil ( n =  5), Zambia ( n =  3), Cameroon ( n =  2), Malawi ( n =  2), and South Africa ( n =  2), and one each in Ethiopia, French Guiana, Japan, Malawi, New Zealand, Nigeria, Somalia, and Slovakia, Uganda, and Zimbabwe. Twenty‐seven studies were conducted in prisons, two in jails, two in juvenile facilities, three in other detention facilities, and four in a combination of facility types. Twelve studies discussed the prevalence of normal menstruation, premenstrual syndrome, or details about menstruation such as age of menarche or length of menstrual cycle. 36 , 46 , 51 , 52 , 82 , 97 , 99 , 112 , 129 , 134 , 152 , 156 Three studies reported a prevalence of regular menstruation between 13/115 (11%) and 806/1198 (76.4%). 46 , 82 , 156 In another, only one woman of 14 interviewed reported normal cycles. 52 Several studies in juvenile facilities reported 12–13 years as the mean or modal age at menarche, similar to a comparison group from one study of non‐institutionalized young people. 36 , 97 , 99 , 129 , 152 Studies reported a 29%–67% (20/29) prevalence of “PMS,” severe premenstrual symptoms, or bothersome periods. 36 , 51 , 112 , 156 Studies addressing normal menstruation. Twenty‐four studies discussed access to care for and management of normal menstruation, most of which centered on a lack of adequate supply of menstrual products, with many people relying on donations from outside groups like non‐governmental organizations or churches or on their families to bring in period management supplies. 30 , 38 , 39 , 40 , 51 , 63 , 68 , 70 , 71 , 76 , 94 , 101 , 113 , 114 , 119 , 125 , 126 , 135 , 136 , 147 , 148 , 149 , 150 , 154 The number of these studies is high, and they almost uniformly describe inadequate access to period products and a lack of autonomy in obtaining the products they need, with one study reporting that people must approach male correctional officers and provide specific reasons to request products. 72 Another study discussed a lack of access to a toilet early in the morning, which was often when participants reported discovering that their period had started. 136 One study, in contrast, stated that “83.89% [of respondents] indicated that the availability of women's hygiene articles was not a problem.” 102 A survey found that 64/65 (98%) of institutions reported that they asked patients about menstrual cycles on intake and/or physical examinations. 155 Outside discussions of access to management of normal menstruation and experiences of normal menstruation during incarceration, no studies focused on special considerations for management of normal menstruation in these settings. Ten studies discussed experiences of normal menstruation by people experiencing incarceration. 31 , 35 , 52 , 64 , 71 , 73 , 95 , 120 , 137 , 156 Much of the focus of these was on the impact on self‐esteem and powerlessness that menstruating without proper access to period products has, how this is another area where the prison has control, and the people menstruating experience humiliation and violation of privacy. 31 , 52 , 71 , 73 , 95 , 120 , 156 Studies also discussed the alternatives people used to manage menstruation in response to the lack of adequate supply of products, including using “newspapers by rubbing the numbers to make them more absorbent.” 137 Many studies regarding access to products for managing normal menstruation and exploring the ways incarceration impacts experiences of normal menstruation met our inclusion criteria, and most focused on the inadequacy of period products and the shame and lack of privacy and autonomy that accompany menstruating while experiencing incarceration. Seventeen studies addressed abnormal uterine bleeding (AUB) (Table  4 ). 6 , 21 , 26 , 44 , 46 , 52 , 76 , 77 , 81 , 82 , 95 , 126 , 134 , 140 , 142 , 144 , 156 These studies were performed in the USA ( n =  8), Brazil ( n =  2), the UK ( n =  2), and one each in French Guiana, Greece, India, Italy, and Japan. They took place in prisons ( n =  11), jails ( n =  1), and other or multiple institutional facilities ( n =  5). Prevalence of AUB was discussed in 13 studies and ranged from 6.4% (of 507) to 88.7% ( n =  102). 6 , 26 , 44 , 46 , 52 , 81 , 82 , 126 , 134 , 140 , 142 , 144 , 156 A study in a UK prison found that 49% of women reported their periods changed following imprisonment. 156 Deboscker et al. found that nearly all study participants in a French Guianan prison experienced changes in their menstrual cycle during incarceration. 52 Studies addressing abnormal uterine bleeding. Four studies emphasized special considerations for AUB, including a lack of access to hygiene products and trauma history. 21 , 76 , 95 , 126 Access to services was discussed in three studies, and key themes were the receipt of an inadequate number of menstrual products and a lack of full‐spectrum medical and surgical management options for AUB. 81 , 95 , 126 For example, Kraft‐Stolar, in a New York state report, describes women reporting hysterectomies performed for abnormal uterine bleeding without proper education regarding alternatives to major surgery. 95 In the USA, Ingram‐Fogel found that many individuals with menstrual difficulties reported not seeking health care as they found the prison system to be unresponsive, and they did not trust the health care they were given. 81 The effect of incarceration on the experience of abnormal uterine bleeding was discussed in four studies. 77 , 95 , 126 , 156 Multiple studies discussed a lack of education for patients in carceral settings around the causes and options for management of abnormal uterine bleeding. Overall, abnormal uterine bleeding is highly prevalent in carceral facilities, with patients reporting a lack of education around their conditions and diagnoses, decreased autonomy related to medical decision‐making, and not enough access to either menstrual products or gynecological providers while incarcerated. After excluding studies included in past systematic reviews on cervical dysplasia and HPV in people experiencing incarceration, there were 56 studies that met our inclusion criteria (Table  5 ). 20 , 23 , 27 , 28 , 34 , 38 , 42 , 43 , 45 , 46 , 48 , 49 , 50 , 53 , 54 , 55 , 58 , 59 , 60 , 62 , 69 , 78 , 79 , 81 , 85 , 86 , 88 , 89 , 90 , 91 , 92 , 94 , 95 , 96 , 98 , 104 , 105 , 106 , 107 , 108 , 109 , 111 , 113 , 118 , 122 , 123 , 124 , 125 , 126 , 129 , 135 , 140 , 143 , 146 , 147 , 155 They were performed in the USA ( n =  23), Brazil ( n =  10), the UK ( n =  3), Colombia ( n =  2), India ( n =  2), Russia ( n =  2), Spain ( n =  2), and one study each in Australia, Botswana, Canada, France, Ghana, Italy, Malta, Mexico, Peru, South Africa, Thailand, and Venezuela. Most took place in prisons ( n =  37), and 10 were in jails, with 9 in other or multiple institutional facilities. Forty‐one studies reported a prevalence of cervical dysplasia (1/38 [2.6%]–47/157 [29.9%]) and HPV (8/214 [3.3%]–44/93 [52.7%]). 20 , 23 , 27 , 28 , 34 , 38 , 42 , 43 , 45 , 48 , 49 , 50 , 53 , 54 , 55 , 60 , 62 , 79 , 81 , 85 , 90 , 91 , 92 , 96 , 104 , 105 , 106 , 107 , 108 , 109 , 111 , 113 , 118 , 123 , 124 , 125 , 126 , 129 , 135 , 140 , 143 Studies addressing cervical dysplasia and HPV. Special considerations affecting management of HPV and cervical dysplasia in people experiencing incarceration were discussed in 14 studies and often centered on HPV vaccination status and histories of sexual abuse. 20 , 53 , 54 , 58 , 59 , 60 , 79 , 86 , 88 , 89 , 92 , 95 , 135 , 147 Other key themes included a delay or lack of proper follow‐up care or procedures, structural and financial challenges, competing demands, and lack of stability. 89 , 95 A study in a US prison found that women who had sexual intercourse at an earlier age or experienced sexual abuse were more likely to enter prison with cervical dysplasia. 43 Emerson et al. found that in a US jail, age was a risk factor for out‐of‐date Pap smears; the odds of up‐to‐date cervical cancer screening decreased by 5% ( P  < 0.05) for every 1‐year increase in age. 60 Access to services was discussed in 20 studies. 46 , 59 , 60 , 69 , 78 , 79 , 81 , 85 , 86 , 94 , 95 , 98 , 104 , 111 , 118 , 122 , 126 , 135 , 146 Pereira Borges reported that 38 of 56 women (67.86%) incarcerated in a Brazilian prison received guideline‐concordant screening. 122 US carceral facilities and administrators who believed offering the HPV vaccine was important were more likely to provide other preventive sexual health services; just 39 of 50 states reported offering the HPV vaccine to incarcerated females in juvenile facilities. 78 , 98 Incarceration affecting experiences of cervical dysplasia and HPV was discussed in four studies. 60 , 89 , 95 , 111 Women with a history of incarceration had higher rates of reported cervical cancer and abnormal Pap smears compared to women without this history. 58 There is an abundance of data on cervical dysplasia and HPV compared to the other gynecological conditions studied, detailing the high burden of these conditions in populations experiencing incarceration and the challenges of achieving universal preventive, screening, and follow‐up care. Eleven studies addressed genital warts in prisons ( n =  2), juvenile facilities ( n =  3), other detention facilities ( n =  3) or a combination of settings ( n =  3) (Table  6 ). 25 , 32 , 42 , 49 , 54 , 62 , 66 , 104 , 119 , 133 , 142 Five studies were performed in the USA, three in the UK, and one each in Australia, Italy, and Mexico. From 10 studies, the prevalence of genital warts was 3/110 (2.7%)–12/132 (9.1%), 36/378 (9.5%) while incarcerated and 33/474 (6.9%) of participants reporting a history of prior genital warts. Examining conditions with shared risk factors, Nijhawan et al. reported an equal rate of genital warts in patients who tested positive for trichomonas ( n =  5/53, 10%) and those who did not ( n =  31/325, 10%), and a study of juveniles experiencing incarceration reported that 1.7% of adolescents disclosing ecstasy use reported genital warts in the past year compared to 1.6% among those without ecstasy use (OR 0.91, 95% CI 0.32–2.61). 119 , 142 Studies addressing genital warts. One study discussed special considerations for managing genital warts in carceral settings, noting that only 84/214 (39.2%) of participants in a survey knew that HPV vaccination could prevent genital warts. 54 One study discussed access to services for patients with genital warts, noting a new female genito‐urinary consultant was hired to increase onsite testing and access to treatment for conditions including genital warts. 104 One study discussed experiences of genital warts in the carceral setting, with 152 of 214 (71%) juvenile facility participants reporting that they would feel embarrassed to have genital warts. 54 Prevalence of genital warts was reported in many studies that met our inclusion criteria, but there were limited data addressing the other key questions. There were five studies (USA, n =  3, UK, n =  2) that discussed gynecologic malignancies among people experiencing incarceration; four were conducted in prisons and one in a combination of prison and jail settings (Table  7 ). 30 , 87 , 95 , 123 , 124 Prevalence of gynecologic malignancies was discussed in four studies, all of which reported on the prevalence of cervical cancer. The prevalence of cervical cancer ranged from 6/583 (1.0%) to 15/601 (2.5%). 87 , 123 Another study reported a 9% combined prevalence of premalignant or malignant conditions of the cervix. 124 In the fourth, individuals in jails and prisons had increased odds of cervical cancer compared to a non‐institutionalized population (OR for jail 4.16, 95% CI 3.13–5.53, OR for prison, 4.82, 95% CI 3.74–6.22). 30 One study also mentioned that “several cases of ovarian cancer were also diagnosed” but did not report a specific prevalence. 124 Access to services for gynecologic malignancies was discussed in one study, which stated that “patients reported delays in gyn care leading to symptoms worsening and delays in diagnosis and treatment of cancer and cervical dysplasia.” 95 Studies addressing gynecologic malignancies. Special considerations for management of gynecologic malignancies for people experiencing incarceration and experiences of gynecologic malignancies in carceral settings were not discussed in any studies. There are minimal data on gynecologic malignancies in populations experiencing incarceration, and what does exist largely focuses on cervical cancer, further highlighting both the burden of and emphasis on cervical dysplasia and cancer that occurs in this population. There were eight studies that discussed menopause during incarceration (Table  8 ). 22 , 47 , 72 , 83 , 84 , 139 , 153 , 155 Five studies were performed in the USA, one in the UK, one in Brazil, and one in Germany. Six studies took place in prisons and one in both prison and jail; the German study was conducted in an unspecified facility. Two studies reported on prevalence: a study in southeastern US prisons found that 30% of 327 of women surveyed reported “menopause problems,” with a higher rate in Black women compared to non‐Black women. 22 In a North Carolina prison, 382/863 (32.8%) of all prescriptions in the facility were found to be relevant to menopause; the most prescribed medication type that can be used to manage menopause ( n =  346, 30.9%) was selective serotonin reuptake inhibitors, and 68 (6.1%) were hormonal therapies. 84 Special considerations affecting menopause care during incarceration, discussed in five studies, included the impact of coexisting medical conditions and poor general health. 22 , 72 , 83 , 84 , 139 Two studies discussed the high prevalence of coexisting medical conditions, including hypertension, cardiovascular conditions, and mental health conditions in people experiencing incarceration that complicates management of 22 , 84 Jaffe et al. reported a rate of 40/1120 (3.6%) of individuals aged 45–75 receiving estrogen‐containing menopausal hormone therapy. 84 Studies addressing menopause. Access to services was discussed in three studies. 83 , 153 , 155 Two studies only briefly mentioned that the patients in the facilities they studied were asked about symptoms of menopause or provided education about menopause. 153 , 155 One qualitative study discussed a lack of access to lifestyle management of menopause, including replacement clothing and clean bedding to manage abnormal bleeding and night sweats associated with the menopause transition as well as few ceiling fans and no air conditioning. 83 Incarceration affecting the experience of menopause was discussed in two studies. 47 , 83 Participants raised issues including a lack of menopause knowledge and the threat of disciplinary action for certain methods of coping with menopause symptoms such as sleeping without underwear to help with hot flushes. 83 The studies on menopause in carceral settings highlight the complexity of caring for these patients given their lack of access to lifestyle management techniques and the high prevalence of comorbid conditions that affect pharmacologic management of menopause. There were no studies that discussed pelvic organ prolapse in individuals experiencing incarceration. Thirteen studies discussed pelvic pain, although this was not the primary focus of any of these studies, but rather the discussion of pelvic pain was embedded in studies on other topics, most commonly in studies on sexually transmitted infections (Table  9 ). 46 , 70 , 74 , 77 , 95 , 108 , 109 , 128 , 140 , 142 , 144 , 154 , 156 These studies were from the USA ( n =  5), Brazil ( n =  2), and one each in Botswana, Ethiopia, India, Switzerland, and the UK; 10 were conducted in prisons, one in a jail, and two in juvenile facilities. Twelve of these studies reported the prevalence of pelvic pain in patients experiencing incarceration, which ranged from 5.1% ( n =  6/121) to 54% (of 111). 46 , 70 , 74 , 105 , 107 , 108 , 109 , 128 , 142 , 144 , 154 , 156 Most studies reported on pelvic pain in general or primary dysmenorrhea, although the focus of one paper was on bladder pain, and another reported the prevalence of “endometriosis/ovarian cysts.” 128 , 154 Studies addressing pelvic pain. One study discussed special considerations for management of pelvic pain, reviewing the importance of informed consent for treatment of patients experiencing incarceration. 95 One study mentioned access to services for pelvic pain with study participants finding “health care inappropriate for their needs and not set up to handle female diseases … [including] endometriosis.” 77 Five studies discussed experiences of pelvic pain while incarcerated. 77 , 95 , 109 , 128 , 156 A participant in one study reported feeling disempowered and distressed by the care she received related to pelvic pain due to a lack of adequate explanation. 95 In another study, participants reported that their dysmenorrhea worsened during their incarceration. 156 These studies highlight the range of prevalence of pelvic pain in people experiencing incarceration. The qualitative studies that include direct quotes from participants highlight the impact incarceration has on pelvic symptoms, contributing to worsening pain and a lack of control in managing these symptoms. Seven studies addressed urinary incontinence, including two from the USA, two from the UK, and one each from Australia, Brazil, and Pakistan (Table  10 ). 56 , 72 , 103 , 124 , 128 , 130 , 155 Six studies took place in prisons, and one took place in a jail. Five of these discussed the prevalence of urinary incontinence, ranging from 14% (2/14) to 93%, with one study reporting that most patients over the age of 50 have urinary incontinence. 56 , 103 , 124 , 128 , 130 One study discussed special considerations for managing urinary incontinence in the carceral setting, citing one patient's inability to follow recommendations to keep a voiding diary due to the diary being confiscated by an officer. 72 Three studies discussed access to services for patients with urinary incontinence. 56 , 72 , 155 One survey found that 46/65 (71%) of respondents reported being asked about urinary incontinence at their intake visit. 155 Another mentions that patients must ask officers for incontinence pads. 72 Studies addressing urinary incontinence. Three studies discussed experiences of urinary incontinence during incarceration, highlighting the condition's impact on quality of life. Reported experiences included restricting food and water intake to manage incontinence, worrying about malodor due to incontinence, and choosing to delay treatment until a return to the community. 56 , 72 , 128 The studies demonstrate a relatively high prevalence of urinary incontinence in people experiencing incarceration and the barriers that providers and patients experience in managing urinary incontinence during incarceration, including lack of privacy and lack of free access to sanitary supplies. There were 36 studies that discussed vaginitis among people experiencing incarceration (Table  11 ). 24 , 33 , 37 , 61 , 62 , 65 , 66 , 68 , 70 , 74 , 75 , 77 , 79 , 87 , 93 , 95 , 96 , 97 , 100 , 104 , 107 , 108 , 113 , 116 , 119 , 121 , 122 , 129 , 131 , 132 , 136 , 138 , 142 , 144 , 152 , 154 The studies were conducted in the USA ( n =  11), Brazil ( n =  5), the UK ( n =  3), two each in Australia, Slovakia, Spain, and Switzerland, and one each in Canada, Chile, Colombia, Ethiopia, Ghana, Iran, Portugal, and Malta; 20 were conducted in prisons, three in jails, one in a combination of prison and jail sites, eight in juvenile facilities, and four in other detention facilities. Prevalence of vaginitis was defined variably across 32 studies as the presence of specific microorganisms, vaginal discharge, or vaginal pruritis. 24 , 33 , 37 , 61 , 62 , 66 , 68 , 70 , 74 , 75 , 79 , 87 , 93 , 96 , 97 , 100 , 104 , 107 , 108 , 113 , 116 , 119 , 121 , 122 , 129 , 131 , 132 , 136 , 142 , 144 , 152 , 154 Studies addressing vaginitis. Overall vaginitis rates ranged from n =  5/85 (6%) to n =  16/26 (62%). 24 , 61 , 70 , 74 , 75 , 97 , 107 , 108 , 119 , 122 , 129 , 144 , 154 Several studies reported specific rates of Gardnerella vaginalis or bacterial vaginosis (7/66 [3%]–10/25 [40%]), trichomonas vaginalis (25/583 [4.3%]–329/556 [59%]), and candida species or yeast organisms (1/53 [2%]–91/486 [19%]). 24 , 33 , 37 , 68 , 74 , 79 , 93 , 96 , 100 , 104 , 108 , 113 , 116 , 119 , 121 , 131 , 144 , 152 Among women with HIV incarcerated in Rhode Island, 27/110 (25%) had vaginal candidiasis. 62 Among patients being treated for trichomoniasis, there was a co‐infection rate of 25/583 (4%) for candida vaginitis. 87 Individuals in a juvenile facility who had used ecstasy previously were more likely to report vaginal discharge or odor (OR 2.33, 95% CI 1.16–4.65). 142 Special considerations for management of vaginitis in carceral settings were discussed in two studies and included giving patients the option to self‐test and the high rate of recurrence attributed to limited hygiene facilities. 79 , 138 Access to services was discussed in four studies. 65 , 77 , 104 , 138 One study described the process of accessing care and included a quote from a patient who had received advice from a nurse to exaggerate symptoms to have requests for medical care related to vaginitis be taken seriously. 65 Another study found that women identified a lack of resources to maintain hygiene as a contributor to the development of vaginitis. 77 One study improved access for vaginitis care by hiring a female genitourinary consultant. 104 A study from Ghana described an intermittent lack of availability of drugs to treat candidiasis. 138 Incarceration affecting experiences of vaginitis was discussed in one study that mentioned a patient feeling like they were not receiving adequate communication or education as to why they were having recurrent yeast infections. Prevalence of vaginitis was commonly reported in studies about gynecologic care in carceral settings, highlighting the commonality of this complaint in this population. Experiences of vaginitis in carceral settings centered on difficulty accessing care for treatment and theorizing that hygiene practices in some facilities affected vaginitis rates. Four studies addressed the prevalence of other conditions (Table  12 ). 25 , 26 , 134 , 154 Young reported a rate of 6/129 (4.7%) of “endometriosis/ovarian cysts” in a US prison. 154 Rowe and Waters noted premature ovarian failure in 25 patients in a Massachusetts facility in 1935 (one attributed to oophorectomy, 10 attributed to prior gonorrhea infection, and 10 without a proposed etiology). 134 A 1965 presentation of data from a Los Angeles juvenile facility reported 102 cases of cervical erosion and one case of an absent vagina. 25 Andrade et al. reported a rate of 58/146 (39.72%) of ultrasound abnormalities in 146 patients experiencing menstrual irregularities in a Brazil prison. 26 Studies addressing other conditions.

Synthesis of the 135 studies included in this review demonstrated both that gynecologic conditions are common in carceral settings and that disparities in the experience of gynecologic conditions have three underpinning mechanisms. First, there are gynecologic conditions that are brought on or exacerbated by the physical and emotional stress of incarceration, such as abnormal uterine bleeding, pelvic pain, or menopausal symptoms. Second, there are shared social and structural factors, such as substance use and physical, emotional, and sexual abuse and trauma that are common among individuals experiencing incarceration and might exacerbate some gynecologic disparities (e.g., cervical dysplasia and cancer). Third, conditions of confinement, lack of access to care, and intersectional stigma intensify the physical and emotional experience of some conditions, including normal menstruation, urinary incontinence, and pelvic pain. These findings enrich and extend the findings of previous, condition‐specific reviews. Conducting this literature review across multiple gynecologic conditions, languages, global contexts, and many decades (1930s‐present) resulted in several important throughlines. A unifying theme across time and place was the lack of adequate accommodations and supplies to manage normal menstruation or any gynecologic conditions that a person might experience during incarceration. Additionally, although we excluded studies focused exclusively on sexually transmitted infections as well as the many studies of cervical dysplasia included in recent systematic reviews, the most frequently addressed gynecologic conditions in our review, apart from normal menstruation, were cervical dysplasia and vaginitis. The persistent and international emphasis on gynecologic conditions related to sexual health would seem to belie the other gynecologic health disparities experienced by people who are incarcerated. Finally, although there have been more descriptions of interventions to improve care for gynecologic health conditions in carceral settings in recent years, there are relatively few studies proposing or testing interventions to address these health needs compared with the number of descriptive studies. There are important policy implications from our findings. Although mass de‐carceration is likely the most straightforward approach to minimizing the gynecologic disparities that result from incarceration, interim steps to improve conditions of confinement are needed. The most urgent of these might be the provision of adequate sanitary supplies for people experiencing normal menstruation, abnormal uterine bleeding, and urinary incontinence. Although philosophies of incarceration and punishment vary across settings, the United Nations Basic Principles for Treatment of Prisoners require treatment “with respect due to their inherent dignity and value as human beings,” precluding shaming and/or degrading incarcerated individuals for their bodily functions. 157 Adequate provision of basic supplies will go a long way toward the humane management of gynecologic conditions, and studies on normal and abnormal menstruation, pelvic pain, urinary incontinence, and vaginitis also emphasized the importance of decreasing stigma and promoting bodily autonomy and self‐determination. The practice of trauma‐informed care (i.e., care that identifies trauma and related symptoms, trains staff on the effects of trauma, and minimizes re‐traumatization) offers a way forward in clinical spaces. 158 Programs such as Amend at the University of California, San Francisco, which bring dignity‐driven and public health‐oriented practices from Norway and elsewhere to improve the culture in US prisons, can serve as a roadmap for carceral systems where trauma‐informed care is not yet the norm. 159 There are also critical changes needed globally to the systems of care that people access during incarceration. The studies we reviewed evinced substantial concerns expressed about the lack of competent and trustworthy providers in the context of accessing routine gynecologic care and care for abnormal uterine bleeding, menopause, and vaginitis. Addressing these gaps in the provider workforce will require multi‐pronged efforts to dismiss or remediate providers who are not prepared to provide trauma‐informed, community‐standard care and to make clinical positions within carceral facilities desirable to providers with the necessary skills. Important steps to accomplish the latter will include improving the physical and human resources in carceral clinical settings, actively destigmatizing carceral medicine as a valued public service career path and establishing universal training in trauma‐informed care. Beyond improvements to clinical services, studies across multiple gynecologic conditions also identified a need for health education about abnormal uterine bleeding and menopause. Although there have been reports of educational interventions focused on reducing risk for STIs including HIV, similar educational programs focused on non‐sexually transmitted gynecologic conditions are limited. 160 , 161 In addition, although the authors are aware of educational activities outside the USA (Knittel, personal communication), fewer of these interventions have been published in the peer‐reviewed literature. Taking inspiration from the internet‐based sexual health empowerment curriculum developed in Midwestern USA, health researchers and educators globally would do well to create low‐cost, easily disseminated, and scientifically accurate educational resources about gynecologic conditions across the life course. 162 Finally, this synthesis of global literature reveals a substantial gap in the literature on studies of conditions that disproportionately affect aging and older adults. We found relatively few studies examining either gynecologic cancer experiences and outcomes or menopause experiences and no studies addressing pelvic organ prolapse. This gap remains more than a decade after the publication of a policy setting agenda to address disparities for those aging in custody that included recognition of their gynecologic needs. 163 This review is not without limitations. Our scoping review methodology included a wide range of studies that varied in terms of methods, clinical focus, and quality. While this allowed us to review the global landscape of gynecologic conditions in settings of incarceration, the breadth precluded meta‐analysis or other quantitative approaches to synthesize findings. We were also limited in our review by a relative lack of intervention trials and publications describing ways to address the gynecologic health disparities identified.

In summary, in carceral settings across the globe, gynecologic conditions are common and often exacerbated by the physical and emotional stress of incarceration, trauma histories, lack of access to care, and conditions of confinement in these settings. Additional research efforts are needed in the arenas of health education and interventions to address gynecologic health disparities, as well as to increase understanding of the gynecologic health needs of aging and older adults. Most pressing, however, is the need for parallel efforts at global de‐carceration and policy interventions to provide for basic gynecologic needs, decrease intersectional stigma, and improve the conditions of confinement.

More than 740 000 people identified as female in intake are incarcerated globally as of 2022, reflecting a 60% global increase since the year 2000. 1 The USA unfortunately leads this trend, with the increase in incarceration among people assigned female far outpacing both those assigned as male in the USA and female incarceration in all other countries. 1 , 2 The scope of this review is global, but considering national disparities in rates of incarceration, much of the framing centers on the US criminal legal system. In the USA, carceral settings include jails, which generally house people awaiting trial or serving short sentences, and prisons, which house people with longer sentences. The terminology used to describe facilities outside of the USA varies, as do the criminal legal structures that determine where and for how long individuals are incarcerated in those settings. 3 Many gynecologic conditions, including the physiologic processes of menstruation and menopause, likely require accommodation for those experiencing incarceration in settings where people lack control over access to menstrual products or lifestyle modifications. 4 , 5 Moreover, managing common gynecologic concerns including abnormal uterine bleeding and cervical dysplasia, which might be more common or less well managed among people who are incarcerated, requires special considerations given the high prevalence of trauma history and the long‐documented history of reproductive coercion by carceral facilities and criminal legal system staff members. 5 , 6 , 7 , 8 , 9 The American College of Obstetricians and Gynecologists states that people experiencing incarceration should have access to the full scope of reproductive care. 5 Historically, however, research on the obstetric and gynecologic healthcare needs of people experiencing incarceration has focused on pregnancy care, sexually transmitted infections, and cervical dysplasia. 10 , 11 , 12 , 13 Recent reviews highlighting the difficult realities of contraception and abortion access in carceral settings and the ongoing high prevalence of human papilloma virus (HPV) and cervical dysplasia and cancer among people experiencing incarceration reflect the prioritization of these issues. 7 , 14 , 15 , 16 The aim of this review was to answer the following questions: (1) What is the prevalence of benign and malignant gynecologic conditions among people experiencing incarceration? (2) What are special considerations for managing benign and malignant gynecologic conditions in carceral settings? (3) What is access to services for benign and malignant gynecologic conditions like during incarceration? (4) How does incarceration affect experiences of benign and malignant gynecologic conditions?

The authors report no conflicts of interest.

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