V. Findings: Specific Women’s Health Concerns

Human Rights Watch interviewed women about their ability to access medical care for the full range of their health concerns while in detention. To gauge the system’s preparedness in policy and in practice to address the particular needs of women, the interviews included in-depth discussions of women-specific health concerns. This chapter presents our findings on those issues, as well as findings on care for survivors of violence and on mental health care, both of which emerged in our research as priority issues for women in detention.

Routine Gynecological Care

As a group for whom routine, but consequential and potentially painful reproductive healthcare issues arise frequently, women stand to suffer considerably within a medical system that emphasizes emergency care and treating conditions that “would cause deterioration of the detainee’s health or uncontrolled suffering affecting his/her deportation status.”[160] Although individual providers may conceive of their role more broadly, policies set at the national level establish a framework that is startlingly inadequate in addressing common gynecological concerns. The Covered Services Package warns providers that non-emergency gynecological services are usually not a covered benefit, though requests may be approved on a case by case basis, effectively limiting care to whatever minor interventions may be available at the facility clinic or, if the woman is lucky, through Division of Immigration Health Services (DIHS) approval of outside care.[161] This overall approach, as well as specific restrictions on Pap smears, hormonal contraception, and access to specialist care, undermined the health of a number of women who spoke with Human Rights Watch.

Pap Smears

Cervical cancer represents the second leading cause of cancer deaths among women worldwide.[162] However, the Pap smear, a simple and inexpensive screening test, is capable of detecting 90 percent of early cellular changes in the cervix that signal an increased risk of cancer, allowing for life-saving interventions.[163] Accordingly, Pap smears have become a mainstay of routine preventive health care for women in the US. The American College of Obstetricians and Gynecologists and the American Cancer Society recommend that beginning within three years of sexual activity or after the age of 21, women receive a Pap smear annually until they reach the age of 30. After age 30, women who have had three negative Pap smears can be screened every two to three years. Women who have reached the age of 65 with no abnormal results in the last 10 years may be safe to discontinue screenings.[164] As Dr. Homer Venters testified before Congress during a hearing on problems with medical care in immigration detention, Pap smears represent one of “the most beneficial and cost-effective measures of modern medicine.”[165]

Women in ICE custody cannot count on accessing this essential screening with the frequency recommended above. According to ICE Policy, women must generally spend a year in ICE custody before becoming eligible for a Pap smear screening.[166] Pap smears may be considered before that time if “medically indicated”[167] or if a specific problem is brought to the attention of the medical providers.[168] On its face, this policy does not correspond to the community standard because it does not account for when a woman may have last had a screening before entering detention. Several women told Human Rights Watch that they had plans for an annual exam right around the time they were detained, while others had not had the opportunity for a screening in years. Standard setting bodies for correctional institutions such as the National Commission on Correctional Health Care and the American Public Health Association avoid this problem by recommending that Pap smears form part of jails’ initial health screening for women, to then be followed up with periodic screening according to community standards.[169]

Interviews conducted by Human Rights Watch confirm that women are indeed being denied this critical screening. Of eight women interviewed who had been detained for more than a year, six women had not received a Pap smear,[170] one had been screened once in two years of detention,[171] and another had received the test when she was receiving attention for other medical concerns.[172] In some cases the women actively pursued the screening; in others they were unaware of their potential eligibility because medical personnel had not mentioned it.

Cecile A., detained for 18 months at the time she spoke with Human Rights Watch, said she had stopped trying to get the test after multiple attempts: “In Texas I asked. I submitted a request and they said yes but they never called. In Texas I asked many times but here [at a Florida detention center] I don’t think they do it.”[173] Cecile A. and the other five women we spoke with whom ICE detained for over a year without a Pap smear were in detention at the time we interviewed them, making it impossible to assess the impact of the missed screenings on their physical health. However, the understandable impact of this uncertainty on their mental health was readily apparent. Expressing distress over the number of Pap smears and other cancer screenings she had not received over the course of two years in detention, Nana B. said, “I think because I have been here a long time they need to do all the tests ... I don’t know if I’m sick or not. I’m scared.”[174]

Improvements in the eligibility criteria for Pap smears at the national policy level likely constitute only the first step toward ensuring access to screenings at the facility level. If the experience of Lucia C., who met all of the current requirements for Pap smears, provides any indication, implementation poses its own challenges. Prior to her detention by ICE, Lucia C. had obtained a Pap smear and learned that the result was abnormal. Her doctor instructed her that she should follow up with Pap smears every six months to check for signs that cervical cancer was developing. When ICE detained her at a county jail in New Jersey, Lucia brought her situation to the attention of medical authorities. Initially rebuffed, she persisted: “I was supposed to be checked every six months. I asked my daughter to send the records. I got it and I brought it to medical so they could see I’m not lying. I have asked a lot of times.”[175] Speaking with Human Rights Watch after almost 16 months in detention, Lucia C. reported that the medical staff still had not provided her a Pap smear. “It’s terrible,” she said, “because you feel like you have something you can die for... and you don’t have no assistance.”[176]

Hormonal Contraception and Gynecology Appointments

DIHS policy denies women in ICE custody access to basic family planning services including contraceptive drugs, interfering with their reproductive autonomy, and exposing them to the risk of unintended pregnancy and unnecessary hardship. Furthermore, several women reported struggling to obtain appropriate attention for menstrual irregularities and other gynecological concerns through the detention medical care system.

Out of step with American Public Health Association correctional standards mandating access to contraception, the Covered Services Package specifically disclaims coverage for family planning services of any kind and the DIHS formulary omits hormonal contraceptives.[177] DIHS officials told Human Rights Watch that hormonal contraceptives for birth control were not available because they constitute an elective therapy that is not without risks.[178] In addition to blocking access to birth control, Human Rights Watch found that this policy can also impede women from obtaining access to hormonal contraceptives as treatment for other health conditions, including painful or irregular menstruation.

Despite the limitations that a sex-segregated detention setting might seem to imply, the lack of access to contraceptives can put women at risk for unintended pregnancy. Instances of sexual contact between men and women in detention centers, while rightly forbidden given the impossibility of meaningful consent in such an environment, have occurred and women should not be required to report sexual abuse in order to obtain needed services.[179] Further, women’s time in detention must be viewed in the context of their larger reproductive lives. On release from detention, women who had been forced to discontinue their use of hormonal contraceptives would not immediately be able to rely on that method due to the time it takes for hormonal contraceptives to become effective.[180] It is notable that the Federal Bureau of Prisons, which cares for women who will generally be out of the community for longer periods, provides women with advice and consultation about methods of birth control and will prescribe it when deemed medically appropriate.[181]

In addition, hormonal contraceptives serve a number of important purposes beyond birth control. Among their many uses, hormonal contraceptives may be prescribed to reduce a woman’s risk of developing ovarian and breast cancer, to regulate a woman’s menstrual cycle, or to alleviate painful menstrual cramps.[182] Three of the health services administrators who spoke with Human Rights Watch indicated that the exclusion of family planning services from the Covered Services Package and DIHS formulary would not prevent hormonal contraception from being prescribed for a medical issue aside from birth control.[183] However, for Serafina D., that was exactly the effect it had:

I was having ovarian problems where I was bleeding very heavily and [my medical providers before I was detained] told me that I had inflammation of ovaries and because the bleeding was so heavy they prescribed birth control ... Birth control would make it soft and light. When it was heavy it was very uncomfortable. Cramping, heavy, like I was hemorrhaging ... [In detention] they couldn’t give me the medications because they don’t provide birth control. “We don’t [provide that] kind of medication.... The only thing we can give you is ibuprofen as an anti-inflammatory.” I was glad when I didn’t have my period for two months but then when it came, ahhhh. I wouldn’t want to get up.[184]

Women unable to obtain gynecological appointments reported that, in some cases, the difficulty was directly attributed to the requirement that national headquarters authorize outside appointments for specialist care. Before ICE detained her, Nadine I. had made arrangements to see a gynecologist for painful menstruation-related concerns.[185] She said, “A week before I got my period I would be in agony. I would pass heavy, huge clots.”[186] At one Florida detention center, she put in four or five requests to see a gynecologist and understood that the medical facility had sent in the required papers for DIHS authorization to make the appointment. After six months passed without a response, she was transferred to a second facility in another part of the state. There she again filed a request. It was not until more than four months later, over 10 months from her original request, that she saw a gynecologist. During her months of waiting, she said, “They wouldn’t give you anything.”[187]

Several other women repeated similar stories of difficulty obtaining attention for gynecological concerns but never received an explanation for the delay. In two instances, the requests simply went unanswered. After she was detained, Jameela E. started getting her period every two weeks. She put in multiple requests to consult a doctor without success.[188] Lily F., who arrived at a detention center in Arizona and immediately sought follow up for an abnormal Pap smear, waited months to be sent for treatment. Transferred from a prison in California, she had the good fortune of having her medical records follow her to ICE detention, including the abnormal Pap results, but it still took six months for the facility to arrange for her to go off-site for a biopsy.[189]

Sanitary Pads

They only give two pads. In the morning they come and give you two. If you need more than that you have to go to the nurse. “Why do you need more pads?” You have to tell her, “Because I bleed so much.” But it has to be an extraordinary reason. If it’s normal for you to have a heavy period—nothing. I bleed through three pairs of pants. Well yes, if the officers see this, then it’s a reason.

—Nana B., Arizona, May 2008

Women at several facilities described arbitrary and humiliating limitations on access to sanitary pads. ICE standards state that facilities will issue feminine-hygiene items on an as-needed basis.[190] However, as implemented in several detention centers, this policy has failed to meet the UN Standard Minimum Rules on the Treatment of Prisoners requirement that authorities provide individuals in custody with “water and with such toilet articles as are necessary for health and cleanliness.”[191] A number of women told Human Rights Watch that officers would distribute a certain quantity of pads (two to six), and obtaining more “as needed” posed a challenge. Nadine I. recalled that after you used your allowance of four pads, the officers would hand them out one at a time. “I needed three pads. It would just gush. It would end up soaking my clothes. If my clothing got soaked, I could go through a shift change without a change of clothing ... We were shaken down every night. If you had hoarded they would take [away] the extra pads.”[192]

Such restrictions put women in the place of having to justify to staff—and often not the medical professionals—the needs occasioned by a private bodily function. Elisa G. had her period when the detention center decided to lock down her entire housing unit for three days. The circumstances forced her to appeal to the ICE officer visiting the unit: “I had to ask [for pads] again. ‘I have my period. I have a lot of pain. I need to shower. It’s not for [my benefit], it’s for my roommate.’ [ICE officer:] ‘Give this lady two pads.’ I said, ‘Sir, you’re not understanding what I am saying. I need more than two pads,’ ... I had to just sit on the toilet for hours because I had nothing else [I could] do.”[193]

Several women at one facility expressed anger over a recently instituted rule at that particular facility that required women to work to receive any sanitary pads beyond their initial allotment.[194] “I don’t have any problem with working, but I don’t feel that it is right that you have to do that to get what you need,” said one woman.[195] Upon learning of this rule, the ICE field office said this rule was against policy and would be taken up with the facility immediately.

Mammography and Breast Health

I worry about my breast a lot. I told my family, “Don’t ask me to [appeal my immigration case].” I’m not well and I would have to stay without medical care. I don’t know from month to month ... things can get worse in my breast. It’s hurting me. What was I supposed to do, die of cancer here? With adequate care, yes, I would stay until the end. Because 22 years of my life [have been in the US]. My kids are 12 and the United States is all they know. Depression, inadequate food, detention? Yes, still I would have fought it indefinitely.

—Antoinette L., Arizona, May 2008[196]

Topping even cervical cancer, breast cancer ranks as the leading cause of cancer deaths among women. Calling mammograms “the gold standard” for early detection of the disease, the American Cancer Society recommends that women age 40 and over receive the screening yearly along with a clinical breast exam from their health care provider, and that younger women undergo the clinical exam every two to three years. The American Cancer Society also counsels providers to tell women in their 20s and older about the benefits and limitations of breast self-examinations.[197]

The DIHS approach to breast health is deficient in how it addresses all three modes of breast cancer screening. National policy limits access to mammograms and is completely silent on manual breast exams and self-exams. The DIHS benefit package provides that mammography requests will be considered for asymptomatic cases only after an individual has been in custody for one year and only if that the individual is not facing imminent deportation.[198] As discussed in regard to Pap smears, the one-year requirement contradicts advice that these tests be administered annually, since it does not take into account when the woman last obtained a screening prior to detention.

Four women who spoke with Human Rights Watch who had been in custody over one year had not received either a mammogram or a manual breast exam.[199] Another woman had recently had surgery on her breast before being detained and was instructed to get a mammogram every six months. Due for her six-month mammogram at the time she was detained, she had to wait four months before the detention authorities arranged for a mammogram, and did not receive another one during her remaining 12 months in detention.[200]

Those women who have breast health concerns that require examination and follow up care find the uncertainty around their health compounded by uncertainty around the procedure for obtaining appropriate medical attention. The Covered Services Package does not set out separate rules on eligibility for diagnostic mammograms. However, presumably they would fall under the rubric of procedures that might be authorized if supported by clinical findings.[201] Two women felt their lives were in jeopardy due to ICE’s failure to follow up on concerns related to breast cancer. Antoinette L., quoted above, waited months for a mammogram. When one was finally performed, and it was determined that at least one of two lumps required further investigation, no plan of action was formed; rather, she was told that this was something she should pursue after leaving detention, whenever that might be.[202] During Lily F.’s months-long wait for a mammogram she felt increasing discomfort—“It’s like something bite[s] me”—and worried with thoughts of her mother’s death from breast cancer: “I have kids,” she said, “I don’t want to die here away from my family.”[203]

Pregnancy

Prenatal and Postnatal Care

Pregnancy is one of the few women’s health concerns ICE leadership has begun to address with appropriate gravity in policy, but this improvement is limited by uneven implementation. It is ICE policy that medical personnel immediately inform ICE when they discover a woman in custody is pregnant in order that those responsible for case management can monitor her progress and assess whether alternatives to detention might be available. For the duration that prenatal and postnatal women are in custody, the ICE benefit package states that prenatal exams are covered services and the new ICE medical standard will provide that “[f]emale detainees shall have access to pregnancy testing and pregnancy management services that include routine prenatal care, addiction management, comprehensive counseling and assistance, nutrition, and postpartum follow up.”[204] As it stands, however, access to these services appears to vary considerably.

ICE contends that all pregnant women in detention receive care from off-site obstetrical specialists, two of whom we spoke with and confirmed that they provide the detained women with care commensurate with community standards. Martha Burke, midwife at Su Clinica Familiar in Harlingen, Texas, sees pregnant women detained at Willacy County Detention Center and told Human Rights Watch that “What’s available to them is what’s available to everyone.”[205] Restrictions in the DIHS health coverage or in the logistics of transporting women for services do not pose a problem according to Dr. F. Javier del Castillo, who provides care at his practice in Brownsville, Texas, for women detained at Port Isabel Service Processing Center: “If I say the lady needs an ultrasound on Sunday, she’ll get it on Sunday.”[206] Three women who visited off-site providers expressed satisfaction with the services.[207] Speaking of the Brownsville practice, Katherine I. said, “They [ICE] sent me to the doctor three or four times, a women’s clinic in Brownsville.... They did a sonogram twice, checking everything. They treated me well. There’s nothing that needs to be changed about Brownsville.”[208]

However, we spoke with three women in Arizona who never reached an outside provider and for whom these services never materialized. In two of those cases, the women told the medical staff of their pregnancy but tested negative on the urine test the DIHS facilities use to detect pregnancy in all detained women who are of child-bearing age. While accurate most of the time, urine tests cannot predict pregnancy as early as blood tests.[209]

Failure to schedule necessary tests in a timely manner can also delay or effectively deny access to prenatal care. Giselle M., pregnant for the first time, entered ICE custody after her doctor identified an ovarian cyst that threatened her five-month pregnancy and her health but, despite bringing her need for frequent sonograms to the attention of ICE, never obtained a prenatal exam of any kind during a month and a half in detention:

When I went to get a sonogram [before being detained] the doctor found a cyst and wanted to monitor every two to three weeks because it kept growing, growing to the size of a golf ball. It could erupt and hurt me or the baby. I was a first time mom, I didn’t know what to expect. I told them [at the detention center] this is what is going on and I need to see a doctor. I would go every time with my little paper. They would say, “Go ahead, put [in] a request.” But they never took me once. They never got back to me.[210]

Giselle M.’s medical record indicates that the health unit planned to include her the next time they arranged a visit with the prenatal care provider, but did not make any accommodation for her to see a specialist more quickly given her circumstances. After almost a month had passed from when she was supposed to have had a sonogram according to the schedule set by her doctor, Giselle filed another sick call request asking about when she would have an appointment. The response from the medical staff read, “You are scheduled to see PA soon, within 2 wks. Be patient.”[211]

Abortion

The Division of Immigration Health Services lists “elective abortions” as an example of “commonly requested procedures” that are generally not authorized under the Covered Services Package. Several of the health service providers we questioned about the accessibility of abortions indicated that ICE would not provide or fund an abortion for a woman in custody, but could arrange transportation to an appointment paid for by the woman herself or a third party. For many women who arrive in detention without significant personal funds or connections to resources in the immediate area, arranging to pay for the procedure, which can cost hundreds of dollars, may be impossible. Detention health care providers emphasized that abortion rarely comes up and some could not remember it ever arising at all. In contrast, legal and social service providers noted the frequency of sexual assault along the border and recalled clients seeking access to abortion following incidents of rape. By comparison, unlike women in ICE custody, women in the custody of the Bureau of Prisons may receive an elective abortion at Bureau expense if the pregnancy is the result of rape.[212]

The reference to abortion not “coming up” underscored the apparent omission of options counseling for women who test positive on the pregnancy tests all women receive at intake.[213] The DIHS Policies and Procedures Manual, which provides instructions to staff at DIHS-operated facilities, requires providers to screen all women between the ages of 10 and 55 for pregnancy, and to follow up on positive results with notification to ICE and initiation of prenatal care. But there is no recognition of the possibility that a woman might not wish to continue the pregnancy.[214] Indeed, one provider confirmed that unless the woman articulates a desire to terminate the pregnancy, it is “care as usual.”[215] Three women confirmed that they received no such counseling and one indicated that she had planned to seek an abortion before being detained and would have requested one in detention if that option had been explained to her:

You know when you find out you’re pregnant you feel excited. That’s normal. But I didn’t feel that way. I was indifferent. I had been thinking about abortion ... But the doctors [at the detention center] were going to want me to tell them why I am thinking about that. In that moment, if I had the option I would have done it [abortion] ... I didn’t know that there were those kind of services available.[216]

According to standards issued by the National Commission on Correctional Health Care, “pregnant inmates [should be] given comprehensive counseling and assistance in accordance with their expressed desires regarding their pregnancy, whether they elect to keep the child, use adoption services, or have an abortion.”[217] The Federal Bureau of Prisons requires wardens to “offer to provide each pregnant inmate with medical, religious, and social counseling to aid her in making the decision whether to carry the pregnancy to full term or to have an elective abortion.”[218] The new ICE medical standard states that pregnant women will have access to “comprehensive counseling and assistance” as part of “pregnancy management services” but does not elaborate on what this entails, whether it covers information on abortion, how it will be made available or who will be responsible for providing it.[219]

The duty to provide options counseling as a component of pregnancy testing is especially important in the immigration detention context, where desires to terminate a pregnancy may not be expressed because women are unaware of the options that are legally available in this country. It is incumbent on facilities to provide each pregnant woman with, at the very least, a statement of the law and referrals to trained counselors for more information as desired.

Nursing Mothers

Recent policy changes limiting the detention of nursing mothers should prevent many women from having to contend with the detention health services’ deficient approach to lactation. However, gaps in implementation of the new policy raise concerns that women and children will continue to suffer the short- and long-term effects of the scant medical attention offered to nursing mothers in custody.

In a November 2007 directive, then Assistant Secretary Julie Myers instructed ICE Field Offices to consider paroling all nursing mothers who did not meet the criteria for mandatory detention[220] and who did not present a national security risk.[221] Nonetheless, two of the five nursing mothers who spoke with Human Rights Watch had entered detention since the directive despite being eligible for parole under its guidelines. In both cases, it appeared that there had been a breakdown in communication between health services personnel and the case management authorities in charge of parole decisions. The directive instructs field offices to update ICE headquarters regarding decisions to detain nursing mothers; however, there does not seem to be a functioning system for health services staff to alert immediately field offices of the presence of nursing mothers, as they must with pregnant women. In fact, when Human Rights Watch queried health services administrators about their approach to lactation, none made reference to the directive.

Women entering detention as nursing mothers, whether because they meet the criteria for mandatory detention or because they have been overlooked for parole, face considerable hardship, much of which could be avoided with the most basic and inexpensive of interventions: a breast pump. Officials at DIHS headquarters informed Human Rights Watch that breast pumps should be made available to nursing mothers.[222] However, of the five women who spoke with us about their experience of being detained while lactating, none were offered the option of using a breast pump when they presented for medical intake.[223] The absence of this option caused intense physical discomfort including fever, chills, and pain. Jennifer L., detained at two facilities in Texas, recounted, “I told them at [the first detention center], and they called me after two-three days. They gave me a little bit of pills for fever but the breasts were full. And the fever was permanently in my body. No pump, no compress, no ice.”[224] Similarly, Ashley J., detained in Arizona, said, “The ducts clogged. I felt very bad. [My breasts] were so full my arms hurt. I couldn’t move my arms.”[225] In at least one case, mastitis resulted when these concerns went unaddressed.[226]

In addition to causing severe discomfort, the abrupt halt to lactation has significant long-term implications for the woman and her child. The women who spoke with Human Rights Watch had intended to continue breastfeeding their children, in some cases, for years beyond the point of their detention, as is typical in some cultures. Women who breastfeed benefit from a reduced risk of breast and ovarian cancer, and their children are less likely to suffer from pneumonia, viral infections, and, research suggests, possibly obesity and diabetes.[227] Despite one health services administrator’s contention that they had the option of manually expressing milk, none of the women who went without a pump were able to breastfeed after their release. Apart from depriving mother and child of the physical benefits of continued breastfeeding, this carried with it mental anguish for several women. “My focus was that I couldn’t nurse my child. I could not go back to nursing,”[228] said Ashley J. Mercedes O. remembered, “When I was thinking that my daughter would look for me to nurse and I couldn’t, I felt useless.”[229]

Services for Survivors of Sexual and Gender-Based Violence

While it is impossible to say what percentage of the women detained by immigration authorities have survived sexual or gender-based violence, observers’ estimates and the risks associated with migration suggest it is high, and possibly climbing.[230]Even though this violence does not affect women exclusively, Human Rights Watch considers it an important topic to address in assessing the detention medical care system’s response to women’s health needs. One health services administrator told Human Rights Watch that she thought almost all the women in her care were touched by domestic violence;[231] at another facility a health official said that women reporting rape during border crossing “is not surprising for us. Routinely we see it.”[232]

Among the women who spoke with Human Rights Watch, many reported some form of sexual or gender-based violence in one or more stages of the migratory process. For some, violence created the impetus for leaving their country of origin: “I was afraid of my husband because he was abusing me and if I go back he may do something to me,” said Yesenia P.[233] For others, it transpired over the journey: “There was no lock on the door to the bathroom [at the house where the coyotes kept us]. I had my back turned in the shower when they came in ... afterwards I saw the condoms on the floor,” said Suana Michel Q.[234] For still others, it formed part of their experience in the US: “Little by little I came to be in a relationship where [my husband] had the biggest control over me because of my being illegal. He had total control over me,” said Ashley J.[235] For almost all, the violence had repercussions that persisted at the time of their detention, such as severe mental distress.

In addressing the needs of survivors of sexual and gender-based violence, inconsistency among detention centers’ approaches means that some women benefit from a comprehensive approach to their mental and physical health, but many go without any recognition of their needs. Both the American Public Health Association and the National Commission on Correctional Health Care recommend that women in custody receive services to address those needs.[236] The APHA standard states that, “Health care for incarcerated women should include services that address the consequences of abusive relationships. The safety of women should be ensured and care should be provided for the physical and emotional sequela of abuse.”[237]

ICE policy fails to comprehensively address the needs of survivors of violence. During the recent revision of the detention standards, ICE added a standard on preventing and responding to sexual assault. While this is an important improvement, the standard focuses on sexual assault that takes place in ICE custody, and does not specifically address the needs of survivors whose assault predates their detention. Discussions with facility health services administrators and women currently or formerly detained by ICE highlighted some existing positive practices but also weaknesses in several areas: the identification of survivors, the range of services available to address the short- and long-term consequences of violence, and the cultivation of partnerships with community service providers.

Providing clear opportunities and safe spaces for women to disclose their experience with violence is essential for ensuring the well-being of women in custody, both because they may have urgent medical needs and because the experience of detention may retraumatize them. The new ICE medical standard directs facilities to question all detained persons at their initial medical screening about past or recent sexual victimization, but only advises questioning about other forms of physical abuse for individuals referred for mental health evaluations.[238] Despite assertions by facility providers that they ask about violence during medical intake, a number of the women who spoke with Human Rights Watch did not recall ever being asked. In cases where abuse or assault formed the basis for the woman’s claim for immigration relief and would likely have been known to her deportation officer, these issues still went unaddressed on the medical side. Nora S. said that this subject did not come up with the detention staff: “I only spoke about this in court.”[239]

Failure to identify survivors of violence during initial screenings may be linked to the phrasing of the question and the person by whom it is asked. On one intake form, the question is asked, “Have you ever been the victim of a sex crime?”[240] In addition to leaving out the most common form of gender-based violence—domestic violence—the question may fail to elicit information because of confusion over what constitutes a crime. National and international standards on such screening typically advise a series of questions about specific behaviors or incidents given the varying ways in which individuals, especially those from diverse cultural backgrounds, may define violence or crimes.[241] In addition, in many cases, women may only be willing or comfortable disclosing violence to a healthcare provider of the same gender. As noted above, the initial medical screening at ICE facilities may be conducted by personnel who are not medical professionals. Further, detainees are not necessarily screened by someone of the same gender.

An early opportunity for an effective discussion of these issues is particularly important for women who have suffered sexual violence immediately preceding their detention. Otherwise, they may miss the window for time-sensitive interventions such as emergency contraception (EC) and prophylaxis for sexually transmitted infections (STIs), as well as the collection of physical evidence of the attack. Health services administrators told Human Rights Watch that while most women would have passed the time period for EC to be effective at the point they reached the detention center, the medication could be made available when appropriate, as could treatment for STIs, crisis counseling, and referral to a local hospital for forensic evidence collection. Despite the administrators’ statements regarding the availability of EC, the medicine is not on the detention center formulary and, unlike STI prophylaxis, it is omitted from the list of interventions to be made available to rape survivors in the new standard on sexual abuse and assault prevention and intervention.[242] Officials from DIHS headquarters insisted that as an “emergency” intervention, EC would be obtained in one manner or another to ensure a woman would have timely access to it.[243]

Women in abusive relationships may also have immediate needs and concerns for their safety. Ashley J. recounted the continuing torment her abusive husband inflicted on her while she was in detention: “He would tell me that he knew deportation officers and that he could see the videos of how I was behaving. I believed that he could reach me inside, in detention.”[244] Ashley J. informed her deportation officer of the situation so that he would not provide her husband with information on her case, but she was not referred by the officer for services nor was the subject broached by health care providers.

For women whose experience with violence dates back further, the needs for medical attention may still be acute. Human Rights Watch spoke with two women, Nana B. and Jameela E., who suffered gynecological problems while in detention that they attributed to female genital mutilation performed in their country of origin. Regarding mental health care, Nora S., a survivor of domestic violence, stated affirmatively, “I would definitely have wanted help with this, the opportunity to talk about this. I was a victim of domestic violence for 13 years.”[245]

Finally, a hallmark feature of one facility’s successful response to one survivor’s assault was the detention facility’s partnership with a local service provider. According to Suana Michel Q., the health providers at Port Isabel Service Processing Center referred her to the Family Crisis Center in Harlingen, Texas, who provided her with counseling during her stay in detention and afterwards when she was released into an alternative to detention program.[246] Moreover, when she moved out of state, the facility provided her with a referral to a similar organization at her destination. Unfortunately, not all detention centers coordinate so closely with local resources. An advocate for sexual assault survivors in Arizona told Human Rights Watch that she had repeatedly sought to engage her local ICE field office in a dialogue on ways they could cooperate to serve the needs of survivors but found them uninterested.[247]

Mental Health Care

Human Rights Watch decided to probe further on care for mental health issues because it emerged in interviews as a priority issue for many women in detention. When asked about the health concerns women frequently presented, several health services administrators noted that women would commonly seek care for depression or anxiety.[248] This held true in Human Rights Watch’s interviews with women who were or had been in detention.

According to the women we spoke with, the facilities’ response to mental health concerns ranked as one of the greatest deficiencies in the detention health care system. In part, this failing represents one more manifestation of the detention standard and benefit package’s emphasis on acute care. The currently binding ICE medical standard provides for a mental health screening, but does not elaborate on what treatment is available.[249] The new ICE medical standard shows improvement in that it stipulates that every facility shall provide mental health care to the individuals in its custody and that a treatment plan will be devised for individuals with mental health needs.[250] However, the extent to which an effective treatment plan can be implemented may be limited by the off-site services authorized under the DIHS Covered Services Package, which states that non-emergency services are generally not covered and that counseling and psychotherapy are not covered unless approved by the medical director.[251] DIHS officials assured Human Rights Watch that counseling is available and that medication would not be prescribed alone but as part of a comprehensive treatment plan, as is contemplated in relevant health standards.[252]

However, a number of women cited difficulty obtaining counseling or accessing other options for treating mental health concerns beyond medication alone: “I’ve never been offered therapy but I have asked for information to try to get something done but I’ve never received any replies . . . [The clinic manager] keeps telling me that there is nothing that the institution can do with us because we are not going to be here for a very long time,” said Itzya N., who at the time had already been detained for more than four months.[253] Her severe depression led the facility to twice place her on suicide watch and to prescribe her increasingly strong doses of medication, but without a complementary course of therapy, as she requested. Beatriz R., on the other hand, said she had been told that counseling was available but was never able to avail herself of it: “They say, ‘Oh, you can speak to a counselor anytime you want.’ But they’re not there or they’re busy. Before they said they would call me. I don’t know who the counselor is. They never called me to talk with the counselor.”[254]

Several women who had suffered from depression or anxiety told Human Rights Watch that they were dissuaded from even seeking help by the knowledge that, at best, they would get medication but no counseling or therapy.[255] Others delayed or decided against reporting their mental health concerns out of fear that they would face negative consequences.[256] Maya Z. said that facility staff as well as other women detained at the facility advised her to cope with her anxiety problems by herself because bringing it to the attention of medical staff might result in a transfer to a less desirable facility.[257] Another woman found that the medical staff immediately interpreted a request to speak with a psychologist as an indication of suicidal ideation. After her request, the staff asked her if she wanted to kill herself, to which she responded that she would rather be dead than have been taken into detention, but that she had no intention of harming herself. She was immediately put on lockdown for several days, which only compounded her distress and dissuaded her from raising the issue again.[258]

The medical system’s focus on crisis intervention also serves to exclude preventive care for individuals who develop depression and anxiety in response to the experience of being detained. Women, both those who have pre-existing mental health concerns and those who do not, face a host of stressors brought on by detention. These may include separation from children and family members who depend on them, uncertainty about whether they will be allowed to remain in the country, trauma from their arrest, and the deprivation of their liberty inside the facility. One DIHS healthcare provider acknowledged to Human Rights Watch that detention does take a toll on mental well-being but added that the medical staff has limited options for alleviating these stressors before the situation degrades to the point where intervention by mental health professionals is necessary.[259]

These needs might be met through the assistance of a social worker who could, for example, make inquiries into the well-being of separated family members or contact deportation officers to discuss the case management of individuals having a particularly negative response to detention. But the women we spoke with pointed to even smaller interventions that, where available, helped a great deal. Comparing two facilities, Nora S. said that at the first one, a service processing center, they “had the heart to help.” This, she explained, meant that “they would give us paper, pens to write our families every day,” and offered her opportunities to call her family, as opposed to the second facility, a contract detention center, where she was unable to call her family for four weeks. “I mean the fact that they were allowing people to communicate with families is emotional support because it is very hard to be locked up,” Nora S. said. The facility’s enabling them to reach family members meant that they “were not abandoned.”[260]