The Sociology of Death: Forensic Pathology and Society

Forensic pathology is the scientific, medico-legal process of determining the cause and manner of death. Sociology is broadly defined as the empirical study of institutional and structural processes that shape and modify our social world. Using Stefan Timmerman’s publication Postmortem: How Medical Examiners Explains Suspicious Deaths as a foundation, this essay will illustrate how the field of forensic pathology is intimately grounded in sociology, and highlight the various structural and institutional interactions that affect the practice.

When a human dies, various formal and informal institutions must process the death. The next of kin, loved ones, and acquaintances exemplify an informal institution that intangibly processes death via mourning, remembrance, and emotional adjustment. Forensic pathologists, (also known as medical examiners) are on the opposite end of the spectrum, working as part of a formal institution (i.e. medical examiners office) that aim to explain the physical, pathological process of death via tangible scientific methods like the autopsy.  A multitude of other entities are involved in the human death experience, such as law enforcement, courts, insurance companies, public health organizations, medical subspecialties, research organizations, organ procurement companies, religious institutions, the military, and private enterprise. This intricate web between these entities contains both conflict and collaboration, and illustrates the sociological complexity and logistics of dying.

How is sociology relevant in discussing the work of death investigators? Pathologists do not operate in a vacuum, simply gathering morphological and anatomical data in a fixed procedure. Pathologists use their calculations, measurements, temporal ordering, and causal explanations in a manner that that is never purely pathological, but socially informed (Timmerman 2006). Social context and the data obtained from other agencies and organizations (e.g. law enforcement and primary care physicians) are invaluable. As one chief medical examiner stated “without scene investigation and medical history, I am lost…I can’t do my job” (Timmerman 2006: 70).

While there is much more to dying that just the termination of life, forensic pathologists are the experts entrusted with scientifically and logically determining the cause and manner of death. Their profession is characterized by political independence, autonomy, and strict reliance on the scientific method, but their practice is not without its own unique set of problems. Timmerman makes it clear that forensic pathologists are subject to the influences and external pressures cast upon them by other institutions.            Upholding the highest standards of both medical and legal practice are not always ideals that can be equally met; pathologists may be very conservative in their medical findings due to the potential ramifications of the legal system, which affects how they document their pathological evidence. Shaped by the law, the threat of lawsuit, or a loss of credibility due to challenge of evidence in a courtroom, a legally defensible description of cause and manner of death are of utmost importance (Timmerman 2006).

The fusion of medicine and law, and the administrative and practical challenges in such a fusion are clearly demonstrated in various contexts. “In lifesaving efforts, the exigencies of life and death clash” (Timmerman 2006: 52) in a way that pits the priorities of medical, life-saving care and the need for a thorough and meticulously conducted death investigation. Dr. [NAME REMOVED] (2012), a medical examiner and faculty member of George Washington University, stated in a presentation that as a medical examiner she prefers to receive bodies fresh from a crime scene rather than from a hospital, where interferences from emergency room personnel could contaminate and confound findings for the medico-legal death investigation.

Forensic policy and procedure is hotly debated between pathologists and organ procurement representatives. The debate centers on how to most effectively balance the need for proper legal procedure when someone dies, and expedited organ transplantation to someone who is living and in dire need of a suitable organ. Family members, law enforcement, and politicians may also have very high stakes in whether a death is classified as natural, accidental, suicide, homicide, or undetermined, and will often try to exert influence over that decision making process. The myriad of organizations that both collaborate and contest the work of forensic pathologists exemplifies how other social structures and institutions affect the practice. In the words of Timmerman:

Anesthesiologists and surgeons, midwives and obstetricians, nurse practitioners and primary care physicians, nursing aides and registered nurses, allergists and pulmonologists – the list of groups embroiled in simple turf fights to gain or protect professional power is long. If we add hospitals, research-funding agencies, government regulators and payers, and patients to the mix, struggled over jurisdiction become the rule rather than the exception in the field of medicine (Timmerman 2006: 247).

Forensic pathologists possess as much power as their symbiotic and adversarial partners provide. A lapse in judgment or a flaw in procedure on behalf of the medical examiner’s office can damage an otherwise cooperative and efficient relationship with law enforcement or a district attorney’s office. Their role is of significant sociological and cultural importance, as their expertise determines what can become a cause of death, and what criteria must be met to differentiate manners of death. In line with a Foucauldian perspective of knowledge and discourse translating into power, forensic pathologists, through their calculations and procedures, exercise power over how we understand death. Forensic pathologists are active agents in defining and evolving the definitions of dying. Their contributions make or break court cases, fuel public health campaigns, expose dangerous custodial practices of the state, and shape safety standards in both public and private institutions.  The field of forensic pathology is a vivid and exciting illustration of the sociology of death, and the medical and legal administrative procedures that guide the practice. One cannot say that forensic pathology is too exciting though, because as Timmerman (2006) noted, forensic pathology is a career where it’s troublesome if you hate your job, but perceived as even more disturbing if you highly enjoy it.

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Zona de Tolerancia: Characteristics and Dilemmas of the Colombian Sex Industry

INTRODUCTION

            The sex industry refers to a plethora of services, entertainment venues, and products that meet the demand for sexual stimulation and gratification. It can be divided into occupational categories like prostitution, pornography, and stripping, with each sub-category significantly differing from the other. The sex industry, by definition, is an economic and occupational industry that involves a wide variety of businesses, facilitators, vendors and consumers. This industry is global in scope, and sex tourism represents how certain cities become hubs for domestic and international travelers who seek adult services and entertainment. Legal approaches to sex work widely vary by country, state, and municipality, and these differences in policy have far-reaching ramifications for how sex work is conducted. This paper will examine the public health and legal dimensions of female sex work in Colombia, and address the larger hegemonic discourse on sex trafficking that shapes popular perceptions of sex work generally. The target industry category of this paper is female prostitution (brothels and street-based sex work). Additionally, an analysis of contemporary human trafficking laws and political discourse will illustrate the legal responses to, and skewed understandings of, female sex work in Colombia.

            Sex work in any of its categories is a type of vice: a heavily stigmatized activity that brings sharp divisions in public opinion and political support. Yet prostitution has existed for centuries (Clarkson 1939) and is arguably one of the oldest occupations in recorded history. This paper refrains from taking a stance in the legalization versus criminalization debate, but rather offers a fair and balanced approach to understanding Colombia’s sex industry and its corresponding policies. The orientation of this paper is one that explains the current status of the industry, explores its dilemmas, and offers policy recommendations without placing value judgments on the moral or social permissibility of the type of work. As with other vices, such as gambling and drug use, a harm reduction approach that applies sensible policies in furtherance of regulation and control produces better results for vice participants and non-participants alike, regardless of how stigmatized or unfavorable the activity may be in the eyes of the general populace.

            Much of what we know about the Colombian sex industry comes from a very limited and underdeveloped body of research. Unlike the literature on prostitution systems in other countries, there is a lack of contemporary research on the characteristics and effects of the sex industry in Colombia. Drawing from a narrow body of literature presents a significant challenge to gaining an understanding of how prostitution and the laws that correspond to it operate, but this paper does provide insight into the characteristics and public health challenges of street based and brothel female sex workers. The international discourse and modern day crusade against sex trafficking and how it has produced dilemmas in the functioning of the Colombian legal system is also explored. The following sources are the most contemporary publications and studies on Colombian sex work and human trafficking policy, and they provide much of the data that will be referenced in the paper:

Council on Hemispheric Affairs

Contraception Journal

Indiana Journal of Global Legal Studies

Investigacion y Desarrollo

Journal of Immigrant and Minority Health

Journal of Community & Applied Social Psychology

Revista de Estudios Sociales

Trends in Organized Crime

            The theoretical framework that best applies to prostitution in Colombia is Robert Merton’s anomie theory. Merton posits that there are culturally prescribed goals that are shared among most members of a given society, and there are legitimate institutional means to achieve those goals. Anomie occurs when there is limited access to legitimate means in which to attain these culturally prescribed goals. When the discord between goals and means occurs, anomie, or a state of normlessness, ensues. The goal of economic security, upward mobility, and material wealth is widely shared by Colombia’s population, but not everyone has access to legitimate avenues in which to attain financial prosperity. Merton took interest in what he called innovators, or those who maintain the same culturally prescribed goals but reject conventional means in which to attain them. Income inequality, urban and rural poverty, and internal displacement due to guerilla warfare have exacerbated the lack of access to legitimate means (i.e. jobs, education, skills training) of economic security, prompting some to turn to prostitution as a primary source of income.

COLOMBIA’S SEX INDUSTRY: A BRIEF LEGAL DESCRIPTION

            Brothel-based prostitution is legal and allowed in tolerance zones, or zonas de tolerancia (Bautista et al. 2008). Brothels are venues where sex can be purchased, and some brothels take the forms of strip clubs, gentlemen’s clubs, or adult discotheques. Street prostitution is illegal but not competently enforced. Major cities like Bogota, Barranquilla, and Cartagena have robust tolerance zones that collectively make up Colombia’s international sex tourism industry. A tourist in the coastal city of Cartagena could easily enter a bar or strip club that functions as a brothel, where female sex workers negotiate prices for various sexual acts and services. If an agreement is made, clients can also negotiate that the FSW return to the client’s hotel or place of residence for the sexual service. Additionally, prostitutes often congregate in certain alleys and actively proposition potential customers.

            Government agents from the United States helped to illustrate how the brothel and prostitution system operates in Cartagena. In the summer of 2012, eleven U.S. Secret Service agents were stripped of their security clearances and reprimanded for purchasing sex from female sex workers (King 2012). This prompted a media frenzy and political scandal that questioned the safety of President Obama and the integrity of his security detail. As reported in the United States press, investigations by local authorities revealed that no Colombian laws were violated since prostitution is legal and allowed in that particular zone of Cartagena.

Laws against proxenetismo (pimping) and sex trafficking are stiff, with hard punishments including imprisonment of a minimum of nine years along with fines. Penalties are even more punitive for those who engage in international sex trafficking or egregious exploitation of a sex worker. In other words, obtaining any material benefit from the sex work of another person can classify as proxenetismo and can subject that beneficiary to punitive sanctions. Despite the legal stance on pimping and third party benefits, it is common practice for men to help recruit customers and refer tourists to sex workers. Other contradictions and dilemmas with legal statute versus legal practice will be discussed.

BROTHELS

Bogota is the country’s capital and largest city, and is home to a large amount of female sex workers (FSW). While a reliable estimate of the Bogota FSW population is difficult to produce, in 1990, approximately 14,000 FSW were working in Bogota’s city center, and according to a more recent report, the proportion of FSW in Colombia could be 0.7% of the entire Colombian female population (Mejia et al. 2009).

            There is no uniform regulation of brothels and strip clubs, which creates a haphazard policy environment that is conducive to the development of significant public health problems. Female sex workers are at high risk for contracting sexually transmitted infections (STI’s) and HIV/AIDS due to inadequate methods of sexual protection and the higher number of sexual partners. While most brothels keep records of their FSW staff and mandate periodic medical examinations, actual enforcement remains elusive. Failing to ensure jurisdiction-wide health screenings of brothel workers and failing to provide easy and affordable access to medical care can exacerbate public health problems and result in higher STI and HIV rates than would otherwise be possible through a harm reduction and safety regulation approach.

A 2002 study of 514 female sex workers in Bogota found that 76.4% of the FSW workers in bars, brothels, or clubs, with the remaining 23.6% working the street (Mejia et al. 2009). The study found statistically significant differences in syphilis prevalence rates and condom use during vaginal sex between street FSW and brothel FSW, with brothel workers having the advantage. Existing data support that indoor sex workers experience better working conditions that those who engage in street-level prostitution. Compared to street workers, brothel FSW are more likely to consistently utilize contraception and STI prevention measures, less likely to have a previous STI history, and have a lower prevalence of lifetime abortions (Bautista et al. 2008). This was the first study of its kind in terms of systematically measuring STI rates among female sex workers in Colombia, further illustrating the lack of research on this marginalized, but relatively large population. 

STREET PROSTITUTION

            North American scholars have documented the correlation between street based sex work and the concept of “survival sex”. Street based workers are more likely to be engaging in prostitution as a last resort to meet basic needs, and they generally experience higher levels of violence, exploitation, and risk of disease (Porter and Bonilla 2010). Colombia’s historical civil war and insurgency, paired with economic and political turmoil, have produced significant amounts of internally displaced people. These are contributing factors to why the sex worker population of Bogota is so high.  

A qualitative study of 28 young sex workers and their experience in a rehabilitation program in Bogota found that all participants had suffered traumatic experiences including: physical, sexual, emotional and psychological abuse, gang rape, rape at gun point, bullet and knife wounds, and being kidnapped or sold by relatives, and nearly all of them had been displaced by guerilla warfare (Robinson and Paramo 2007). Juvenile sex workers experienced distorted perceptions of oneself and others, and had negative outlooks on life, the future, and their interpersonal environment (Robinson and Paramo 2007). Children as young as 10 years old work the streets of Bogota, yet the only existing contemporary study of this marginalized and high-risk population involves their experiences in one rehabilitation program and how they perceive the provided services.   

Adult street-based sex workers in the city of Monteria were found to have skewed perceptions of sexually transmitted infections, and did not fully appreciate the risks of contracting an STI. Female sex workers perceived STI’s as a matter of cost and convenience; workers reported that they could simply use some of their earnings to pay for STI treatment (Jimenez, Vergara and Torres 2011). Additionally, they viewed condoms as unreliable luxuries that did not adequately safeguard them against contracting diseases or avoiding contraception. This represents a major public health concern, because even if sex workers had easy, free/affordable access to condoms, their skepticism of condom effectiveness would render condom availability as useless.

The present literature on both brothel and street-based sex workers simply do not give policy makers and researchers enough information to make informed decisions or conclusions about the status of the sex industry in Colombia. But what do we know about Colombian sex workers? We know that age ranges from 10 years old to over 45, and that nearly half of sex workers that participated in qualitative studies started sexual activity before reaching their 15th birthday. Education levels are overwhelmingly low for both street and brothel-based sex workers. Lack of condom use is a salient issue among adult sex workers, and condom use rates are even lower with anal sex.

Surprisingly, despite easier access to psychoactive drugs compared to the United States, Colombian sex workers (both street and indoor) are less likely to use psychoactive drugs. Reliable estimates are elusive, but the current data place use of illegal drugs in sex work between 8 and 14 percent. Marijuana and cocaine are the most popular substances for sex workers who self-report drug use. All of the studies on sex workers anchor their research questions in public health dimensions, like HIV/AIDS, prevalence of sexually transmitted infections, and emotional and psychological health. None of the studies produced in the past 6 years have systematically examined differences in working conditions, income, perceptions of sex work, and vendor-client relationships. Arguably this could be due to the politics and logistics of obtaining funding for conducting research on sex work; funds are more likely to be distributed to researchers who can produce information about viruses and infectious diseases over those who produce more nuanced knowledge on sex work as an occupation (as opposed to being defined as a question of public health).

Lastly, and perhaps most importantly, we know that Colombian sex work is strongly associated and connected to the international human trafficking industry, both in theory and in practice. There are a combination of push factors that further contribute to why sex trafficking occurs, beyond the standard conception of anomie and lack of conventional channels of work and economic mobility. These push factors include the  political and economic turmoil of Colombia, it’s civil insurgency and guerilla warfare, the public corruption of law enforcement official and government agents (particularly at border sites), limited structural and cultural opportunities for women in Latin America all contribute to the prevalence of prostitution, and the maintenance of the international sex industry (Seelke 2010).  However, as the paper explores, Colombian sex workers, conducting their work both domestically and abroad, do not readily meet the stereotypical notion of “trafficked victim” that anti-trafficking organizations so heavily espouse.

INTERNATIONAL DISCOURSE AND HEGEMONIC POLICY ORIENTATIONS

            According to the United States Department of State, Colombia is a source, point of transit, and destination for men, women and children subjected to forced labor and sex trafficking (Council on Hemispheric Affairs 2012). The international demand for sex, paired with lack of legitimate means of economic advancement, has produced conditions favorable to the development of a human trafficking network. Human trafficking is defined by the United Nations as:

 “…the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery, servitude or the removal of organs” (United Nations Office on Drugs and Crime 2013).

Sex trafficking via coercion and deception is a serious violation of human rights. However, there are several issues with estimating the extent of the problem. Human trafficking statistics often refer to people who have been transported across jurisdictional boundaries through third party facilitation, for both sex work and other kinds of exploitative labor, like custodial work and manual labor. In other words, there are data integrity issues when analyzing human trafficking statistics, which often are conflagrated to elicit connotations of sex trafficking, or sex slavery. There is simply a lack of knowing how many people are trafficked across bordered each yet, and what the proportion of those who are trafficked are working in the sex industry versus other types of work (Weitzer and Ditmore 2010).

            Similar to how a moral panic or moral crusade operates, the United States has been instrumental in pushing an international agenda that pressures other countries to take active measures against human trafficking, and by “logical” extension, sex trafficking. Estimates for how many people fall victim to sex trafficking vary widely and for the most part unverifiable and/or very elastic (Weitzer and Ditmore 2010). Conflating statistics on labor and sex trafficking under the crusade against human trafficking generally functions as method of attracting both private and public funding as well as legislative capital in furtherance of exercising more control over the movement of people across borders. It is documented that Colombian laws regarding sex trafficking and third party involvement in prostitution have become so punitive due to the United States influencing the dramatic expansion of forced work laws (which capture both labor and sexual human trafficking) (Abadia 2012). The hegemony is in the form of decreased economic support and funding from the United States to Colombia if Colombian sanctions towards human trafficking had not changed.   

Ko-Lin Chin and James O. Finckenauer (2012) document how governmental organizations, NGOs, and non-profit advocacy groups have erroneously conflated international sex work with sex trafficking. While their study population involves female sex workers outside of Latin America, they find that the experiences of the workers and third party facilitators do not correspond to current conceptualizations of international sex workers. There is considerably less research on the extent and nature of human trafficking in Latin America and the Caribbean than there is on Asia and Europe (Seelke 2011) but the findings from Chin and Finckenauer apply to the international discussion of human trafficking generally. The overwhelming majority of the sex workers in their study were not forced and coerced through threat of violence, or through use of drugs, to enter this industry against their will. On the contrary, most of the women were sex workers within their home country prior to crossing international borders, or were receptive to the option of sex work and sought to increase their earning power by traveling internationally to promising sex markets. In the context of the Colombian sex industry, many Colombian women who cross international borders to continue engaging in sex work reject the victim label for their overseas work, which contradicts the victim/trafficker dichotomy that is so prevalent in U.S. and international sex trafficking discourse (Warren 2012).

            Chin and Finckenauer define sex trafficking and human smuggling in a new typology that challenges the current “official” government discourse on sex trafficking and international prostitution. However, it is important to note that deception and forms of coercion (like debt bondage) do occur and cause serious harm to certain workers. In 2011, Colombian authorities identified 482 cases of children being coerced into sex trafficking, forced labor, and the illicit drug trade by illegal armed groups (Council on Hemispheric Affairs 2012). However, where is the breakdown of those 482 cases, identifying which ones correspond to forced labor versus sex trafficking?

Lastly, they find that the roles of third party facilitators are not comprised of powerful, organized criminal groups that are international threats to human rights, but rather loose networks of people who have fluidity in moving between different roles in facilitating international sex worker movement and placement. The distinction between sex worker and supervisor is relatively fluid, and individual women may alternate back and for the between these roles, blurring the lines of what it means to be a worker (victim) and a facilitator (exploitative trafficker) (Warren 2012). Trafficking is more akin to a type of disorganized crime, where traffickers are mostly small groups or individuals that collaborate on an ad-hoc and “project-specific” basis, instead of the popular depiction of well organized, well financed, well armed criminal enterprises (Seelke 2010).

What ultimately exists in the U.S – Colombian relationship is a form of policy imperialism. The United States seeks cooperation for Latin American allies to control for the smuggling and trafficking of a) drugs, b) arms, and c) humans (Abadia 2012). The fine print of these hemispheric measures to control these three arenas is that the United States can withhold economic aid from Colombia if action is not taken in furtherance of these objectives (Abadia 2012). Increased penalties for proxenetismo (pimping), and third party involvement in the work of prostitutes has been largely a result of pressure from the United States to actively combat human, and by extension, sex trafficking.

POLICY RECOMMENDATIONS

            Regardless of one’s personal stance on the social, legal, and moral acceptability of prostitution, a sensible method of minimizing harm, or what is termed as a “harm reduction” approach, is warranted through public policy. Colombia legally permits sex work, yet fails to provide proactive legal measures to protect the health and safety of vendors (sex workers) and customers. The Colombian government should find ways to channel both public and private funds towards the study of the Colombian sex industry, beyond the public health questions of “how many sex workers have HIV?” Despite having reviewed literature and journals from sources produced in both Colombia and North America, there is a stark void in academic literature regarding sex work and prostitution in Colombia. Policy recommendations are most effective when they are backed by evidence and empirical data, and when such data is missing, any significant policy change is not adequately informed due to a lack of understanding of the current status of Colombian sex work.

            All of the journal articles reviewed for this research that actually conducted primary research of sex workers in Colombian cities were anchored in research questions regarding public health problems like STIs, HIV, methods of contraception and abortion. In fulfilling the goals of harm reduction via promotion and preservation of public health, the following recommendations should be considered by local governments as well as the Colombian legislature: 1) Continue to fund diversion, training, and rehabilitation programs for juvenile sex workers. The data show that juveniles who are engaged in street survival sex experience very negative outcomes, but there are competent and evidence-based rehabilitation programs that have been shown to help reintegrate adolescents back into conventional society (Robinson and Paramo 2007). 2) Ensure that clinics allow sex workers to obtain free or subsidized medical screenings for STIs and HIV, and fund counseling and treatment services so that workers do not carry curable diseases for longer than they have to.

            3) Revisit Colombian abortion laws. It is estimated that about 300,000-400,000 illegal abortions occur every year, because abortion is illegal in all circumstances, including rape, incest, fetal malformation and threat to the life and health of the mother (Bautista et. al 2008). With abortion being the third cause of maternal mortality in Colombia, public health experts should be considering ways of advocating for legislative change, independent of their views on how prostitution should be regulated. Illegal abortions affect sex workers and non-sex workers alike.

            Lastly, and perhaps most ambitious, is the necessity to improve the political and economic status of Colombia. Income inequality and poverty are at disproportionately high levels in this country, which are at the crux of anomie, or the need to pursue illegitimate means to attain income and economic stability. At the macro-level, continued progress must be made against both guerilla and oppressive paramilitary organizations. Compared to the United States, the concept of the Colombian middle class is elusive. There are simply those that have economic capital, and those who do not. Similar to a Marxist perspective, the Colombian class typology is more bivariate; there are the proletariat and bourgeoisie: the haves and the have not’s, whereas the United States has a robust middle class that represents the halfway point between the disadvantaged poor and the wealthy elite. Economic development and increased opportunities for upward mobility for those born into impoverished conditions will ultimately reduce the prevalence of street based “survival sex” workers.

CONCLUSION

            Public and private entities within Colombia need to allocate more funds towards the study of domestic prostitution and international sex trafficking. The lack of academic policy evaluation literature on the topic, paired with the legal status of brothel prostitution, create conditions where sex work is permitted to operate freely but without regulations that safeguard against worker and societal harms. Laissez faire sex work, or prostitution without governmental oversight is subject to problematic effects that could otherwise be prevented through harm reduction policies.  

            Brothel and indoor sex workers experience better health outcomes compared to street workers. Efforts to reduce the amount of street-based sex workers can help control against sexually transmitted infections, HIV, and unwanted pregnancies. Increased funding for medical and health services that cater to the needs of sex workers is warranted, given the high proportion of female sex workers in Bogota and Colombia in general. Lastly, the Colombian government must consider how the international discourse on sex trafficking affects the operation of their criminal justice system. Determining whether increased punitiveness towards third parties in prostitution is actually enforceable should be a priority of Colombian legislators. Taking an active role in defining the extent of the “sex trafficking problem” via academic research funding can also help dismantle the hegemonic discourse that the United States imposes on its allies within the western hemisphere. Despite the lack of contemporary research on Colombian sex work, this paper offers basic insight into how prostitution operates and how the discussion of sex trafficking does not necessarily correspond to the lived experiences of Colombian sex workers.

 

WORKS CITED

Abadia, Gloria. 2012. “Usos y Abusos Del Sistema Penal. Su Uso Como Forma de Emancipacion Femenina: Un Estudio de Caso Del Delito de Trata de Personas en Colombia.” Revista de Estudios Sociales. 42: 104-117.

Bacon, Kathleen and Jade Vasquez. 2012. “Colombia and Peru Facing Mountainous Path to Eradicating Slavery.” Council on Hemispheric Affairs. 32(19).

Bautista, Christian T., Alfredo Mejia, Luis Leal, Claudia Ayala, Jose L. Sanchez, and Silvia M. Montano. 2008. “Prevalence of Lifetime Abortion and Methods of Contraception Among Female Sex Workers in Bogota, Colombia.” Contraception 77:209-213

Clarkson, F. Arnold. 1939. “History of Prostitution.” The Canadian Medical Association Journal. 41(3): 296-301.

King, Pete. 2012. “Secret Service Agents Bragged ‘We Work for Obama’ While Inside Colombian Brothel: Report: Agents and Marines Brought up to 21 Women Back to Hotel; New Secret Service Team in Colombia Conducting Background Checks, Looking for Hooker Terror Ties.” Congressional Documents and Publications. U.S. House of Representatives Documents. Federal Information & News Dispatch, Inc.

Mefia, Alfredo, Christian T. Bautista, Luis Leadl, Claudia Ayala, Franklyn Prieto, Fernando de la Hoz, Martha L. Alzate, Jacqueline Acosta, Jose L. Sanchez. 2009. “Syphilis Infection Among Female Sex Workers in Colombia.” J Immigrant Minority Health 11:92-98.

Porter, Judith and Louis Bonilla. 2010. “The Ecology of Street Prostitution.” Sex for Sale. Edited by Ronald Weitzer. Routledge. p. 163-195.

Robinson, Rebecca and Pablo Paramo. 2007. “Juvenile Prostitution and Community Rehabilitation: An Exploratory Analysis of Beliefs and Values.” Journal of Community & Applied Social Psychology. 17: 237-247.

Seelke, Clare Ribando. 2011. “Trafficking in Persons in Latin America and the Caribbean.” Trends in Organized Crime. 14:272-277. Note: This is an excerpt from a 22 page report prepared for members and committees of the U.S. Congress.

Valencia Jimenez, Nydia Ninna, Gledis Yolima Catano Vergara, and Ana Karina Fadul Torres. 2011. “Percepcion Del Riesgo Frente a Las Infecciones de Transmision Sexual de Trabajadoras Sexuales de Algunos Establecimientos de la Ciudad de Monteria – Cordoba (Colombia). Investigacion y Desarrollo 19(1): 64-87.

United Nations Office of Drugs and Crime. 2013. “Human Trafficking.” UNODC. Retrieved from (http://www.unodc.org/unodc/en/human-trafficking/what-is-human-trafficking.html)

Warren, Kay B. 2012. “Troubling the Victim/Trafficker Dichotomoy in Efforts to Combat Human Trafficking: The Unintended Consequences of Moralizing Labor Migration.” Indiana Journal of Global Legal Studies. 19(1): 105-119.

Weitzer, Ronald and Melissa Ditmore. 2010. “Sex Trafficking: Facts and Fictions.” Sex for Sale. Edited by Ronald Weitzer. Routledge. 

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Cut From a Different Sleeve: Understanding Adolescents Who Self-Injure

Abstract

Non-suicidal self-injury (NSSI) is a type of deviance that refers to the intentional damage to one’s own bodily tissue without suicidal intent and for reasons that are not regarded as socially acceptable. NSSI can take the form of cutting, burning, biting, scratching, and interfering with wound healing. This paper will examine NSSI by focusing on the most prevalent form: cutting. The author will examine the current academic literature on the topic, and expose several of the gaps and shortcomings of contemporary NSSI research. With limited research on NSSI primarily existing in the fields of psychology and nursing, a call to action is given to social scientists in other disciplines to assist in further exploring cutting & self-injury. Brief explanations are provided of how future research and modest policy reform can a) help achieve a more well-rounded understanding of NSSI, and b) enable those who self-injure to receive appropriate care and treatment.

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Introduction

Non-suicidal self-injury (NSSI), also known as deliberate self-harm, superficial-moderate self-mutilation, self-wounding, and parasuicide (Klonsky, 2008) refers to the intentional and deliberate damaging of one’s own bodily tissue, typically resulting in the perception and sensation of pain. Unlike culturally relative forms of self-inflicted pain like tattoos, body piercing, or corrective & cosmetic surgeries, NSSI refers to self-harm that is conducted for reasons that are not deemed as socially acceptable.

NSSI can take the form of cutting, burning, scalding, inflicting blows or banging on the body, scratching, picking, biting, scraping, inserting sharp objects under the skin, interfering with wounds, tying ligatures, pulling out hair, scrubbing away the surface of the skin, or ingesting sharp objects or harmful substances (Inckle, 2010). While the most common form of NSSI is cutting, those who engage in self-injury typically employ multiple methods throughout their lifetime (Klonsky, 2008). While this paper primarily draws data and research on cutting, its application and relevance directly extend to all forms of NSSI.

Relevant Fields of Application

Cutting and other forms of NSSI concern a diverse range of academic and professional disciplines. While the vast majority of academic literature regarding NSSI belongs to the fields of nursing and psychology, the findings and importance of understanding NSSI extend to various other areas. Those in the field of psychology attempt to understand the individual-level corollary and causal factors that lead to NSSI. Nursing and health provider fields incorporate many elements of psychology, but place a significant emphasis on the treatment and patient interactions with nurses and medical practitioners. Nursing and psychology are often intimately tied with the biological sciences, particularly neuroscience. Limited studies have been conducted on how adolescents who self-injure perceive pain, and how their pain threshold is physiologically different from those who do not engage in self-injury (Hooley, Ho, Slater & Lockshin, 2010). Bridging the gap between neuroscience and psychology would give a more complete understanding of the psychology and physiology behind this phenomenon.

Due to the robust association between self injury, psychopathology, and suicide (Klonsky, 2008), research on this topic can create points of departure for sociological inquiry. As the paper presents current literature on the topic, one will be able to recognize the relevance and application to sociology. NSSI and cutting are associated with subcultures, marginalized groups, and a lack of proper emotional outlets for certain groups of people that present spark many sociological questions.

The field of criminology also benefits from further research on NSSI, as the prevalence of individuals with mental disorders is disproportionately higher among incarcerated populations compared to the general population. Correctional facilities, especially juvenile detention centers, would significantly benefit from having a staff that is well educated in the topic of adolescent self injury, so that the most appropriate response can be given when self-injury occurs among detained individuals.

Aspects of Deviance & Control

While it is impossible to categorize any behavior as objectively deviant, NSSI is a form of behavior that is by and large unaccepted and frowned upon by contemporary society. The aforementioned presentation of how NSSI relates to various areas of study and expertise illustrates how NSSI is both a question of establishing how a particular form of deviance arises (psychology), and how to properly treat, control, and minimize it (nursing & psychiatry). Fortunately, the current research on NSSI provides insight on cutting for the sake of understanding the behavior, as well as information and recommendations for how to best treat, control, and respond to individuals who engage in the behavior.  In recognizing that NSSI is a phenomenon that has far-reaching applications for a variety of academic and professional fields, we can now survey the limited data that exist on the topic.

Literature Review

Research on NSSI has been published in the following academic journals:

  • Advanced Emergency Nursing Journal
  • Creative Nursing
  • Developmental Psychology
  • Issues in Mental Health Nursing
  • Mental Health Practice
  • Personality Disorders: Theory, Research, and Treatment
  • Psychiatry Research
  • Psychological Medicine
  • Social Work Research

Using the published research from these nine journals, we can gain a comprehensive understanding of cutting and NSSI in general. As one may be able to notice from the list of academic journals, the vast majority are evenly split between the fields of nursing/medical practice, and psychology (four articles each), with the addition of one article that is grounded in the practice and theoretical framework of social work. The conclusions and recommendations of these articles, while very insightful in introducing NSSI and providing a basic examination of the topic, leave much to be desired.

Current Status of the Issue

The existing academic literature on cutting shows that the demographic most likely to engage in this form and other forms of NSSI are adolescent females. The onset age of any form of self injury is averaged at 16 years of age, with range of anywhere between 10 and 24 years old. In terms of lifetime prevalence, the literature shows a variation of anywhere between 4% and 23% of adolescents engaging in this form of deviance at least once in their lifetime. One study cuts straight to the point and asserts that “there are currently no reliable estimates of the prevalence of self-injury among the general US adolescent population” (Whitlock, Powers & Eckenrode, 2006).

There is growing recognition of the multifaceted functions of self injury and cutting as a means of coping with and expressing traumatic issues and experiences (Inckle, 2010). The qualitative data in the studies illustrate how “cutting is a way of releasing bottled up emotions, stress, anger, feelings of isolation and abandonment, frustration, anxiety, and as a way to relive pain” (Lesniak, 2010). Apart from the desire to alleviate negative emotions, self-injury also serves as a method to punish oneself, communicate with others, get attention, or to escape a situation or responsibility (Klonsky, 2011). While there is a tendency for the nurse practitioners to view cutters as attention seekers (Reece, 2005), the primary motive behind cutting and other forms of NSSI is to alleviate internal tension and personal turmoil, typically when there is no alternative conventional method of doing so.

Findings also show that cutting is associated with individuals who have experienced intense emotional trauma or an emotionally- difficult life circumstance. The lack of a conventional outlet in which to vent negative emotions (like a caring adult who would be able to listen and give positive advice) is a significant factor in contributing to the likelihood of adolescent self-injury (Walls, Laser, Nickels & Wisneki, 2010). Having a death in the family at an early age, experiencing or witnessing domestic violence, low self-esteem, negative perceptions of body image, lack of peer groups or social networks, and lack of familial bonds to others within the household have been labeled as factors that create these negative emotions that cutters seek to relieve.

In terms of viewing cutters and those who engage in NSSI as a marginalized group with shared characteristics, some of the literature did allude to the subcultures or micro-communities that form among those that practice cutting. One article presented an academically rigorous picture of how cutters can come together in online communities to provide much needed support for each other. The functional value of these online message boards and chat-rooms is that online communication may encourage more truthful exchanges; many people report a greater willingness to share thoughts and feelings online than they would in face-to-face situations (Whitlock, Powers & Eckenrode, 2006). This form of communication can be especially advantageous for shy, socially anxious, or marginalized youth, allowing them to exercise their social skills without the perceived risks associated with face-to-face interactions.

With more than 80% of American youth (ages 12 to 17) using the internet and nearly half of them logging on daily, this understudied phenomenon and how it functions in online communities deserves increased attention by those interested in studying NSSI.

Because self-injury is typically a private, secretive behavior that is difficult to estimate in terms of prevalence and demographic characteristics of those who engage in it, the internet provides a unique opportunity for academics to study cutters and those who self-injure outside of a clinical setting, which is where a lot of the academic research takes place.

The articles that are more concerned with nursing and medical treatment of NSSI focus on how medical health practitioners are uneducated and ill-prepared to deal with the needs and perspectives of those who self injure. Often miscategorized as suicide risks, some medical professionals improperly subject self-injurers to inappropriate, often punitively-perceived methods of “treatment”, like being placed on suicide watch or referred to a mental health institution (Reece, 2005). While nurses are federally mandated to report suspected abuse or neglect of an adolescent to child-protective authorities, they are not properly trained in how to recognize the needs of a self-injurer and how to properly care for them when they need treatment for their wounds (Lesniak, 2010).

The perspective taken by current research in the nursing and medical practitioner fields generally emphasize a more individualized, compassionate, destigmatizing approach to handling self-injurers so as to prevent them from feeling like outcasts or inconveniences for the nurses and medical facilities that they visit. One article acknowledges that while some medical practitioners feel ambivalent towards this patient group, they must overcome these feelings through continuing education of nurses and empathetic clinical supervision in order to care for them effectively (Benbow & Deacon, 2011), and go on to suggest ways of educating the cutters themselves on how to properly care for their wounds. This exemplifies a harm-reduction approach, assuming that self injury will remain a constant in society and that a positive method of addressing it would be to educate those who self-injure on how to properly care for their wounds and avoid unnecessary complications like infection, permanent scarring, or delayed healing.

Lastly, a valuable feature of the academic articles that were analyzed is that many of them incorporate the view, opinion, and experience of the individual cutter. Qualitative data in the form of extensive interviews allows for researchers to hear directly from the people who engage in the behavior, unlike other forms of deviance where the population that commits the behavior under study is difficult to track down or interview.

Gaps within Current Research

While the nine articles from various journals provide an insightful slice of information regarding cutting and NSSI, there are many gaps in the current research. Notice that while most of the research has been published recently, none of the articles explore to any great extent the different variables and demographic characteristics of cutters and those who engage in NSSI. No study of the American population can be complete without accounting for the diversity of demographic characteristics that exist in the United States. Age and gender are analyzed in most of the studies, but there is no breakdown or analysis of race, ethnicity, or socio-economic status. This leads one to be unable to neither confirm nor deny that cutting and NSSI is predominately“middle to upper-class white girl problem, as it is anecdotally stereotyped to be.  No study explicitly addressed whether individuals “age out” of NSSI in the way that people typically “age out” of crime. Age ranges were only provided in some studies because that was the maximum age range of the clinical sample.

Additionally, there is no explicit reference or allusion to the correlation that might exist between those who engage or identify with cutting and self-injury, and subcultures like the goth, death metal, or grunge subculture. While research has found that cutters tend to be socially isolated and lacking in social support networks, they do not exist in a vacuum, completely disconnected from social groups or subcultures that they may identify with. The goth subculture, which explicitly conveys messages of morbidity and self-inflicted suffering, is large enough that there are relatively “mainstream” stores like Hot Topic that one can find in major shopping malls that cater to the fashion needs of these individuals. Death metal music has a significant following of its own, and a lyrical content analysis would illustrate how the lyrics reference NSSI and may contribute to a subculture that endorses it. The fact that there is little to no mention of the social groups and group-level characteristics of cutters leaves a sociological gap in current academic literature.

In the nursing articles, there is little to no reference for what specific types of scenarios justify one coming into a hospital for treatment, which may leave one with the assumption that ‘it must have been that they cut their wrists too deep”. The articles spend ample time discussing the interactions between nurses and patients, and the expectations and biases of each, but none of articles specify what type of self-inflicted injury “crosses the line” and lands a cutter in the emergency room. This is important because if cutting your wrists too deeply to the point where loss of blood is significant and loss of life may be likely, then researchers who base their studies on clinical samples are largely underestimating the prevalence of NSSI and the forms in which it takes place in private residence. This is why the study concerning the online chatrooms and message boards is valuable; it allows for researchers to capture what would go completely unnoticed since many of those individuals who post about their NSSI activity wouldn’t necessarily ever end up in the hospital or treatment center.

Another gap in the research is the lack of application of NSSI to prison and juvenile detention facilities. Attempted and successful suicide among prison populations have been well documented within the field of criminology, but non-suicidal self-injury among prisoners who may be emotionally unstable is completely ignored in all of the aforementioned studies.

Only one study mentioned physiological differences between those that cut and self-injure and those that don’t. Most of the articles explained the factors that were associated with NSSI, but none of them explicitly specified factors that would lead one individual to choose NSSI over a more conventional method of emotional release like mediation, exercise, creative writing, outward physical aggression or violence. There are plenty of people who have experience negative emotions during adolescence, or may have been raised in extremely challenging and emotionally-provocative circumstances, but do not resort to cutting or NSSI. What makes the differences? None of the studies addressed this question.

Uniformity of Findings

While the several gaps in the existing academic literature on cutting and NSSI might lead one to believe that the topic is severely lacking in empirical analysis, one can say with confidence that the 9 articles actually provide a very comprehensive, but concentrated, view of the topic. Many of the gaps in research could be more readily addressed by sociologists, social psychologists, biologists, neuroscientists, and psychologists that seek to study the issue from a different angle. The topic of NSSI and cutting is certainly in need of further attention and research, but the existing data and studies do serve as a valid preliminary analyses and explanation of the issue.

In terms of whether the findings of the 9 studies are uniform or widely varied, they are by and large consistent in their a) theoretical frameworks, b) methodology, c) conclusions and d) policy recommendations. Most of the articles provide an unbiased description of how NSSI has a functional value for those that practice it. All of the articles provide an explanation of how their study has limitations and methodological concerns. The authors arrive at conclusions that are compatible with one another, and the nursing articles all agree with the assertion that medical health practitioners need to be better educated on self injury and provide more compassion and understanding to adolescents who need emotional help and attention. The ideal way to describe how these articles fit together is to say that each of the 9 articles serve as complimentary rods and pillars that together create the framework and foundation that future research can fill in and cement.

Methodological Flaws of Existing Research

The most obvious methodological flaw of the existing research is the reliance on samples that are unrepresentative of a larger population. Either the sample sizes were too small (one of them being n=4), or drawn from a clinical population where the characteristics of the sampled individuals cannot be attributed to any larger group. Virtually every article suggests that the type of research contained within the article is preliminary and serves as a starting point for future research, although the articles with quantitative data do provide more generalizable conclusions.

Connection to Other Forms of Deviance

Theoretical Application

In terms of defining deviance down, a concept coined by Daniel P. Moynihan, some of the nursing articles presented cutting and NSSI as a phenomena that is relatively fixed; they certainly do not address it from the perspective of NSSI being something that can be completely eliminated. Benbow and Deacon explicitly state the importance of educating self-injurers on how to effectively look after their wounds, without directly mentioning how society could address the root causes that make people self-inure in the first place. This type of micro-normalization among certain medical health professionals is a form of defining deviance down, which is a concept that describes a type of normalization that occurs when deviant behavior becomes increasingly acknowledged and accepted as more “commonplace” and “here to stay”. The medical community is almost exclusively focused on controlling this type of deviance, not eliminating it, which is a concept that Moynihan emphasizes in his “Defining Deviance Down” article.

NSSI and cutting are forms of deviance that the articles present as a phenomenon that neatly fits Edwin Sutherland’s differential association theory. In this theory, an individual associates with deviant others, which increases the likelihood that the individual (or actor) learns values, motives, techniques, justifications that are conducive to norm violation, which in turns manifests itself into deviant behavior. The articles regarding internet message boards and the phenomenon of social contagion support the notion that informal and marginalized groups form subcultures that may teach potential youth about how to deal with negative emotions in a self-injurious way. Adolescents and adults who are exposed to a cutting/NSSI subculture or who are in a facility where cutting is frequent (as described in the depiction of social contagion in Whitlock, Powers & Eckenrode’s article) are more likely to engage in cutting.

The article by Holt, Blevins & Burkert, Considering the Pedophile Subculture Online draws close parallels to the Whitlock, Powers & Eckenrode, 2006 article regarding NSSI online communities. Both articles explore understudied populations and how their online interactions provide a sociological and psychological window in which to get an insightful glance at the customs, practices, and preferences of a marginalized community. The authors of both articles acknowledge how difficult it is to study these marginalized subcultures, and they all employed similar methods for coding and interpreting the types of interactions that they observed online. Comparing these two articles implies that future research on NSSI could be based on the orientations of producing or contributing to micro-level theories.

John Kitsuse’s Model of labeling theory provides a theoretical framework for how these group interactions and subcultures can come into place. An audience may interpret an individual as socially awkward, unwanted, or as an outcast for being introverted or being associated with some image like being “emo”, “goth”, a “loner”, etc. This individual, who may or may not engage in NSSI, is categorized and treated as a misunderstood individual who is neurotic, overly emotional, and attention seeking. When this labeled deviance or mild and sporadic forms of NSSI cannot be suppressed, over time this individual becomes increasingly isolated from normal others, develops a deviant identity and self-image, and an amplification of deviant behavior takes place. These individuals would then have the inclination to associate with others that have similar experiences, and this is when a subculture starts to emerge. Additionally, the current treatment that cutters receive when they enter medical and treatment facilities contributes to a negative label or low self-worth, shame and embarrassment (Reece, 2005).

Lastly, NSSI is an example of the route that a macro-level theory can take in explaining a form of deviance. None of the articles call into question the socio-cultural composition of American society, or raise questions about the possibility that NSSI is not a ubiquitous feature of human civilization, but rather something is contingent on a certain type of culture or societal system of organization. Sanday stresses the importance of socio-cultural context for the occurrence and interpretation of deviant behavior. While none of the articles raised macro-level questions about NSSI, we still ought to inquire from this perspective. Why does NSSI exist in such high prevalence in Western society but not in other cultures and societies? What is going on in our societal structures and institutions that is contributing to the prevalence of NSSI? How are institutions like the family, schools, social groups, and methods of communication arranged in such a way that gives rise to NSSI? Sanday’s article reminds us of the importance of incorporating macro-level orientations to supplement some of the micro-level orientations that we currently use to account for deviant behavior.

Functional Value vs. Addressing Root Causes

While most of the articles clearly articulate the functional value of NSSI, few of them aspire to understand and tackle the root causes. This academic orientation regarding NSSI represents the opposing perspectives of functionalism versus conflict theory: NSSI can have a valued function, but be born out of conflict-relationships regarding power, control, and affect regulation (Klonsky, 2008). The nursing community is primarily concerned with properly treating and handling cutters and other self-injurers. The literature from psychology gets closer to understanding the root causes and correlations of behavior, but much more research is needed to investigate what makes the difference that leads an individual to self-harm versus choosing another form of emotional expression.

Conclusion: Call to Action for Academics & Health Professionals

Future Research

As the authors of the existing literature explicitly recommend, additional research is needed, particularly in the areas mentioned in the “gaps of existing literature”. Additional quantitative and qualitative data need to be gathered on the various facets of NSSI in order to gain a deeper understanding of how NSSI develops and functions among various societal groups.

Nurse and Healthcare Field Orientations

To better understand cutters and those who engage in forms of NSSI, there needs to be a transition from treating symptoms and managing self-injurers to understanding the factors that lead people to engage in such behavior. Some may argue that it is beyond the purview of a nurse’s occupation to address root causes of; we don’t necessarily expect nurses to focus on the cultural and societal factors that lead to other types of mental illnesses or detrimental behaviors. But this does fall on the responsibility and job description of the social scientist. As mentioned earlier, the gaps in the current academic literature on cutting and NSSI present inviting opportunities for social scientists to plug in the gaps that leave many sociological questions unaccounted for.

Nevertheless, a harm reduction approach that doesn’t stigmatize or give a feeling of punishment and contempt is needed among nurses and health practitioners so that adolescents who self-injure can feel better understood and less like “undesirables”. They do not need to be treated like delusional, suicide-prone attention seekers but rather as people who have no other outlet in which to vent very personally distressing emotion (Reece, 2005). Modest policy reform in the areas of nurse education and training will allow for health care providers to be better prepared to deal with these marginalized adolescents. With cutting being the most prevalent form of non-suicidal self injury, paired with the fact that NSSI practitioners generally employ multiple methods of self injury, educating nurses on how to properly approach cutters and self-injurers will result in a lesser degree of stigmatization and shame that patients currently experience. The increasing number of stories in the mainstream media, as well as the growing number of anecdotal reports by physicians, therapists, school counselors and social workers, suggests that NSSI may be the next teen disorder (Whitlock, Powers & Eckenrode, 2006). With an estimated 1 out of 10 adolescents engaging in some form of NSSI, a call for further research and professional attention is certainly justified to ensure that adolescents and youth issues are addressed in the most competent manner possible.

Works Cited

Benbow, M., & Deacon, M. (2011). Helping people who self-harm to care for their wounds. Mental Health Practice, 14(6), 28-31.

Holt, T. J., Blevins, K. R., & Burkert, N. (2010). Considering the pedophile subculture online. Sexual Abuse: A Journal of Research and Treatment, 22(1), 3-24.

Hooley, J. M., Ho, D. T., Slater, J., & Lockshin, A. (2010). Pain perception and nonsuicidal self-injury: A laboratory investigation. Personality Disorders: Theory, Research, and Treatment, 1(3), 170-179.

Inckle, K. (2010). At the cutting edge: Creative and holistic responses to self-injury. Creative Nursing, 16(4),

Klonsky, E. D. (2011). Non-suicidal self-injury in United States adults: Prevalence, sociodemographics, topography and functions. Psychological Medicine, 41(2011), 1981-1986.

Klonsky, E. D. (2008). The functions of self-injury in young adults who cut themselves: Clarifying the evidence for affect-regulation. Psychiatry Research, 166(2009), 260-268.

Lesniak, R. G. (2010). The lived experience of adolescent females who self-injure by cutting. Advanced Emergency Nursing Journal, 32(2), 137-147.

Moynihan, D. P. (2001). Defining deviancy down. American Scholar

Reece, J. (2005). The language of cutting: Initial reflections on a study of the experiences of self-injury in a group of women and nurses. Issues in Mental Health Nursing, 26, 561-574.

Sanday, P. R. (1981). The socio-cultural context of rape: A cross-cultural study. Journal of Social Issues, 37(4), 5-27.

Walls, N. E., Laser, J., Nickels, S. J., & Wisneki, H. (2010). Correlates of cutting behavior among sexual minority youths and young adults. Social Work Research, 34(4), 213-226.

Whitlock, J. L., Powers, J. L., & Eckenrode, J. (2006). The virtual cutting edge: The internet and adolescent self-injury. Developmental Psychology, 42(3), 407-417.

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SuperMax Prisons: Structured for Failure

Introduction: Survey of Supermax Characteristics

The American correctional system has undergone various shifts in orientations and approaches in attempting to control crime and punish offenders.  The field of corrections experienced an ideological shift during the mid-1970s, in which the rehabilitative and treatment-based philosophies were replaced by incapacitation, retribution, and “get tough” orientations (Gottschalk, 2006). With an ever-increasing punitive attitude towards offenders and their experiences in the correctional system, the creation and expansion of supermax prisons is truly a “logical extension of a system operating on the premise that the only appropriate response to misbehavior is increased punishment” (Haney, 2003, p.129).

A supermax prison is an institution that has the following characteristics: greater levels of restriction, limited visitation and programs, lack of congregate activity, and the increased degree of isolation from other inmates (Mears and Watson, 2006). Craig Haney (2003) describes supermax prisons as being marked by their totality of isolation, intended duration of confinement, reason for being imposed and technological sophistication. Although conditions vary from state to state, many supermax prisons subject inmates to nearly complete isolation and deprivation of sensory stimuli, which are deleterious to the mental health of inmates (Kurki and Morris, 2001). None of the above characteristics conform to the rehabilitative ideal; the supermax prison, as an institution and as a form of punishment, most directly represents the correctional goals of incapacitation and retribution. More to the point, the supermax prison cleanly operates within the correctional theory of incapacitation, which aims to ensure that the offender has minimal chance of reoffending or causing additional harm (Cullen and Jonson, 2012).

 

Supermax Inmates: Serving Hard Time

In the late 1990s, approximately 20,000 inmates were held under the supermax style of supervision (Haney, 2003). Inmates are treated like dangerous, unpredictable beings. When escorted, they are chained and placed in restraints inside their cells, and some are tethered by a leash that is held by at least one guard. They are seldom, if ever, around others without being in some form of physical restraints, and this includes when in the presence of physicians and medical personnel. Supermax inmates typically have the most stern of restrictions on the type and amount of personal property they may possess in their cells, like books, personal effects, and legal materials. In terms of recreation, supermax inmates generally receive about an hour of exercise time, usually in caged or cement-walled areas that offer nothing else but the ability to walk around in circles. The view of the outside world is often limited; if windows exist in the cell, it is usually a very narrow slit high up on the wall.

The technological sophistication of supermax units allows for communication to take place via intercom, and video surveillance is omnipresent. The bulk of monitoring is done electronically; there is very little need for human interaction from a prison management perspective. To add to the abnormal, impersonal nature of having close to zero human contact, video-conference equipment is used when relatives or visitors come to see the inmate. As if it couldn’t get more impersonal, it can! Medical and psychological needs can be handled via television screens and video-conferences, reducing the need for health professionals to meet face-to-face with the inmate (Haney, 2003). The aforementioned details are used to paint the picture that supermax prisons keep prisoners in virtually unprecedented levels of isolation, comparable to a permanent state of solitary confinement.

Ironically, some literature suggests that supermax inmates and staff ought to feel safer due to the limited interaction with others, this is not entirely accurate. The mental health effects of such a form of isolation and the extremely limited human interaction create a violence and outburst-prone setting where inmates have to be treated like volatile and unpredictable beings. While the statistical risk for violence among inmates is greatly reduced in some aspects, like prisoner-on-prisoner stabbings, it is not a universal truth that inmates and staff in supermax prisons feel safer (Mears and Watson, 2006). One study found that the opening of a supermax prison had no effect, and may have even increased, system wide violence, save for one state where a sustained decline of inmate-on-staff assaults occurred (Mears and Watson, 2006, p.235).

Difference from general inmates: drastic mental health consequences

Supermax prisons are controversial because they raise constitutional and humanitarian concerns (Mears and Watson, 2006). Several scholars and advocacy groups equate the supermax experience to cruel and unusual punishment. The reason being is that supermax inmates suffer from one effect that is unique to them, compared to the general population. While negative mental consequences of incarceration are common among all prison populations, much research and literature has found that supermax inmates in particular are extremely vulnerable to developing mental health problems, or exacerbating existing ones, due to the intensity of their isolation and the toll that the supermax environment takes on the individual.

Empirical literature has clearly established that supermax prisons create dramatic mental health concerns regarding psychological pain and emotional damage, and the empirical data that exists has been consistent in documenting these findings (Haney, 2003, p. 130). Inmates become entirely dependent on the institution, lose the ability to organize and initiate their own behavior, experience a lack of meaning and feelings of unreality, withdraw completely from the social world, and become considerably more likely to experience intolerable levels of frustration, resulting in violence and rage outbursts (Haney 2003).  A wide range of adverse symptoms have been found to permeate the populations of supermax inmates compared to general population inmates. Anxiety, panic, rage, loss of control, paranoia, hallucinations, self-mutilations, negative attitudes & affect, insomnia, hypersensitivity, withdrawal, ruminations, cognitive dysfunction, loss of control, irritability, aggression, lethargy, hopelessness, depression, a sense of a pending emotional breakdown, suicidal ideation and suicidal behavior are all found to be more prevalent among supermax inmates than general population inmates (Haney, 2003).

Challenges for reentry: setting up for failure

What is most interesting about the supermax population is the relative lack of attention that they receive when discussing offender reentry. With over 2,000 inmates currently housed in supermax facilities, and the continued, proliferated growth of these institutions of total control (Ross, 2007), it is a legitimate concern and correctional priority to address the reentry complications that these offenders will face. We tend to think that supermax prisons are reserved for the worst of the worst, without realizing that the majority of inmates under supermax confinement have a release date, and will one day reenter society. What is most outraging is the fact that some supermax prisoners are able to max out their sentences, completing their term of incarceration and walking out of prison without any form of post-supervision like probation or parole.

A Pelican Bay Secure Housing Unit study found that an overwhelming majority of supermax inmates had symptoms of major psychological & emotional trauma (Haney, 2003, p. 133-134). The combination of detrimental psychological effects of the supermax environment, combined with the lack of pre-release services, rehabilitation programs, and interaction with other people creates a released inmate that has had zero training in re-socialization or in how to properly take part in society upon release. The lack of work and program requirement impairs the inmate’s ability to find meaning in any daily activity, because all the inmate can do is be in the cell with very limited activities to do.

Unlike the general population, which may have access to pre-release resources and services, supermax inmates are not given the rehabilitation or treatment orientation that general population inmates typically receive. Supermax prisoners are subject to the punishment and retribution style of criminal justice, and wardens are more concerned with maintaining safety and the proper management of these prisoners than with preparing them for life on the outside. The three main challenges that supermax prisoners face upon reentry are a) lack of social skills due to social deprivation and lack of human contact, b) lack of any marketable skills for the legitimate work-force due to the idle time served, and c) drastic physical and psychological ailments that are known to be closely correlated with being under supermax supervision, and which greatly hinder the ability for the released inmate to be an otherwise normal, law-abiding citizen.

What to do about supermax prisons: the need for evidence-based approaches

In the United States, annual criminal justice expenditures now exceed $160 billion (Mears and Watson, 2006, p. 679). Supermax institutions represent a gross misallocation of these criminal justice resources. Academic literature on the value and effectiveness of supermax prisons is haphazard and contradictory, resulting in a wide gap of both quantitative and qualitative data that should be driving correctional policy. Evidence-based crime policy refers to rational, cost-effective policy that is based on empirical data and prior findings. The negative outcomes and effects of supermax prisons are profound. While these effects are unintentional, their pervasiveness calls for reform. Some of the more notable detrimental outcomes are “permanent effects on mental health of inmates, reduction of resources for other uses, impairing successful reintegration, and increased crime and recidivism in local communities” (Mears and Watson, 2006).

Supermax prisons are extremely costly to construct and operate, as they require the most modern of correctional technologies and a high staff to inmate ratio. The recent proliferation of supermax prisons has taken away limited funds from other correctional needs and programs that fall under the state and federal budgets. In the past 25 years, gratuitous amounts of fund have been spent on supermax facilities without even knowing the long-term fiscal cost of maintaining these institutions and whether they have an effect on recidivism or public safety. An evidence-based approach to the supermax dilemma would not allow for such blind usage of taxpayer dollars and government resources.

Supermax prisons provide an example of how the criminal justice system can cause, aggravate, or trigger mental illness, creating the moral question of whether it is the job of the State to allocate funds to correcting the detrimental effects that it imposes. With the State not addressing these issues, what ends up happening is the release of socially incompetent ex-prisoners into society, with a minuscule chance of successful reentry – an outcome that was not intended.  Increased crime and recidivism can be expected if supermax prisoners receive no reintegration, socialization, or educational resources.   In comparing the costs and benefits of supermax prisons, we find that the negative effects that the supermax institutions have caused far outweigh the short term goals of incapacitation and retribution.

Despite the recent growth and surge of dollars allocated to corrections within the past few decades, we simply do not have the data that itemizes the total cost of building, operating, and managing a supermax facility paired with all the costs associated with each inmates needs and activities after release (Mears and Watson, 2006).  Remarkably little is known about the precise objectives of supermax prisons, whether these objective are achieved, what the intended and unintended effects are, and more generally, whether they supermax prisons are a wise investment both financially and in achieving correctional goals (Mears and Castro, 2006). In lacking this empirical data or evidence, we allow for criminal justice resources to be continuously wasted, injecting more dollars into a questionable practice.  The existence of supermax prisons diverts funds away from general population prisoners, reducing the quality or availability of programs and accessibility to resources that could help them reintegrate and enter society more competently.

Unfortunately, due to economies of scale and the unrealistic expectation that prisons will close, my most realistic approach to improving reentry for supermax inmates is to reduce the length of sentences in supermax prisons, and allowing for inmates to have access to educational resources, such as books and educational documentaries and televised programs. The mental deterioration of inmates should be addressed, and supermax prisoners should have some form of stimulation; it is inhumane to lock humans into small cells and give them nothing to do.

Conclusion: More Research Needed, More Advocacy Too

The American criminal justice system is wrought with inefficiencies and chronic problems that require virtual paradigm shifts in how we think of crime and punishment. Supermax prisons represent just one small facet of the justice system, but its ramifications for the field of corrections are vast and have real, pressing consequences ranging from the misallocation of state funds to the permanent damaging of a person’s mental health, which could lead to grim consequences for offenders who are released into the public after experiencing supermax confinement. The incapacitation orientation in the field of corrections does extremely little to address or account for the fact that thousands of prisoners, some of which were housed in supermax institutions, will reenter society (Cullen and Jonson, 2012). Major evaluations should be made as to whether (a) supermax prisons are absolutely necessary, and (b) how correctional resources can be reallocated to ensure that the principles of punishment, incapacitation, rehabilitation and treatment are implemented in a way that improves reentry outcomes for this inmate population. “Needs, theory, and process evaluations should be required of all policies” with the consequence of failing to do so being the chronic misallocation of limited resources (Mears and Watson, 2006). Supermax prisons and the way inmates experience them are in dire need of policy reform, and the solution lies in utilizing evidence-based practices, conducting more applied research to find out what works, tossing out what doesn’t, and having competent advocates that lobby for prison reform.

 

 

Works Cited

Cullen, Francis T. and Cheryl Lero Jonson. 2012. Correctional Theory: Context and Consequences. Thousand Oaks, CA. SAGE Publications, Inc.

Gottschalk, Marie. 2006. The Prison and the Gallows: the Politics of Mass Incarceration in America. Cambridge, UK. Cambridge University Press.

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