(Ir)relevance of condoms in prisons
01-11-1997 by Hernán Reyes
Hernán Reyes MD, ICRC Geneva
This article was presented by ICRC doctor, Hernan Reyes, at the Corrections Health Services Conference, Australia, in November 1997. It deals with the important issue of prisoners and HIV-transmission, transmission that occurs either through sexual activity or intravenous drug use. To limit the former, condoms have long been promoted as the efficient antedote by many western countries. Based on years of ICRC experience working in the complex prison world, this presentation aims to recall that the issue is not so simple.
Presentation for the Corrections Health Services Conference, November 1997, Sydney Australia
The title of this paper is deliberately provocative. At the end of the twentieth century, and furthermore at the end of the second decade of the HIV crisis, how can anybody question the validity of persuading prison administrations on the one hand, and politicians on the other, to agree to the distribution of condoms in prisons? Can the ICRC, knowledgeable as it is after decades of experience visitng prisoners around the world, claim condoms to be irrelevant for prisoners?
The fact of the matter is that it is precisely this first-hand knowledge of prisoners and prison settings that provide the substance for this paper. The delegates and doctors of the International Committee of the Red Cross (ICRC) visit prisoners around the worl d as part of the organization's regular activities. [1 ]
At international conferences such as the one that prompted the writing of this paper, it may be useful that some information be given on prison systems in contexts that are perhaps less well-known to participants from the host country or from countries with similar backgrounds. New issues concerning the critical question of HIV transmission and its ramifications are bound to have very different implications in different regions of the globe.
This paper attempts to address the controversial issue of sexual practices in prison settings and the relevance of condoms in the transmission of HIV. The distribution of condoms to prisoners is to be discussed at this CHS conference in Sydney, as well as at an international meeting to be held shortly afterwards in the UK. Condoms are certainly not a primary concern of the ICRC. However, prison issues, particularly in relation to the health of prisoners, certainly are, and HIV prevention falls within this area of concern.
The examples given here, drawn from ICRC experience in the field, are intended to demonstrate how different cultural settings may call for different solutions. Discussions on sexual practices in prisons are difficult even with prison doctors. The subject is often taboo, and in many cases the actual practices are illegal in themselves. The author has tried to bring up the matter, including the pros and cons of condom distribution, with colleagues in various countries in Eastern Europe (ex-USSR) on the one hand, and in Africa on the other. In both cases, and for completely different reasons, condoms are not being even considered for prisoners. However—and this is a source of some concern—in both regions many doctors seem to have the obviously erroneous conception that Europeans see condoms as " the " solution for preventing HIV transmission through sexual contacts among prisoners.
This paper will try to show that condoms will unfortunately not solve the problem of sexual transmission of HIV even in Western settings, let alone in the contexts mentioned. The important point to be made is that politicians, administrators and even medical staff unfamiliar with prison realities must not be lulled into complacency about HIV transmission just because of the advent of the prison condom dispenser.
It is also to be hoped that some international perspective will be gained from discussions on this theme, and that doctors and prison governors in the aforementioned countries will not receive erroneous messages from " the West " on what they suppose to be the real efficacy of condoms in prison settings.
The subject of sexual violence as an aspect of torture is another subject, and certainly a primary concern for the ICRC in its work with prisoners aroiund the world. It has, however, different connotations, as it implies the deliberate use of sexual violence by a repressive authority, and shall not be dealt with here. There is perhaps more documentation on sexual violence as a means of torture, than on its presence in " normal " prisons, as there are a great many centres for victims of torture that now treat patients having suffered such violence. [2 ]
2. The question of condoms per se
First it should be made clear that the author has no quarrel with the general idea of having condoms accepted in prison systems. In Europe, the issue of condoms has always given rise to considerable debate. In a very few countries, the Netherlands being a case in point, prison authorities are required by law to provide condoms free of charge to prisoners. In many — indeed most—other countries they are prohibited, as is any form of sexual activity between prisoner s [3 ] . Many prison medical services have been reluctant to advocate for the provision of condoms, as they do not want to appear as encouraging homosexual activity [4 ] . A " middle-of-the-road " attitude of laissez-faire has been adopted in some prisons (including the Swiss canton of Geneva, the author's home town), where condoms are made available by the prison medical service although their issue is not officially approved by the prison administration. [5 ]
The question as to whether or not issuing condoms is going to have any major impact on the sexual transmission of HIV in the custodial setting is considered below from several different angles. The reasons given, by politicians and prison authorities, for their not being acceptable for prisoners in many countries have little to do with this type of argument. These reasons range from a global refusal to admit the acceptability of homo-sexual relations [6 ] among prisoners, to arguments of " security " . The former has a lot to do with morals and religion, matters that will not be dealt with here. The main point is that these considerations place a " taboo " on even talking about the subject, let alone dealing with it in a constructive way.
The " security " argument is somewhat difficult to pin down. Some prison officers argue that condoms could be used to strangle people, but fail to come up with actual examples of such use. Other, perhaps more probable, illicit practices cited are the use of condoms for smuggling in drugs and ... liquor!
As the situation now stands in Europe—the attitude of England and Wales remains to be seen, as condoms have finally been accepted for prisoners, but only since the new Labour government came into power—the distribution of condoms is the exception and certainly not the rule. Furthermore, even in the Netherlands, arguably the most liberal country in this respe ct, the system is not working. Condoms, available free in discreet baskets at the entrance of the medical office, are simply not taken [7 ] . Prisoners who personally request condoms do so in the privacy of the consultation and allege they are for " heterosexual sex in the parloirs " . [8 ]
The point being made here is that the distribution of condoms is indeed being discussed in Europe, and that prison administrations and doctors elsewhere are seeing this as a message and as a possible solution for HIV transmission within prisons. Their actual utility, particularly in the type of situations set down below, is perhaps less a topic of discussion.
3. Violence in prisons and its sexual connotations
A. Countries of the former Soviet Union
The ICRC has been working in the countries of the former Soviet Union since 1989 and has had many contacts with prison administrations, prison medical services, related Ministries and non-governmental organizations dealing with prisoner issues. The transmission of HIV has yet to become a serious problem for prison administrations and health services, with the probable exception of prisons in the Moscow region. Although there is no way of ascertaining the prevalence of HIV infection inside the various prison systems, it is generally thought to be low [9 ] . However, quite understandably, prison doctors are worried about HIV, and rightly see that the reality of violence within many prison systems calls at the very least for pre-emptive thinking about the various and most obvious forms of transmission. In order to understand this reality, some general background on prisons in these countries is useful.
The prison system inherited by the successors to the defunct Soviet Union is a complex one [10 ] . In many of these countries, the problem of overcrowding has reached epidemic proportions. In Russia alone there were an estimated 1,350,000 prisoners (on remand and sentenced) within the system in 1996, and the numbers are growing. The issue of prison violence has been documented in Russia and in the other countries of the former USSR [11 ] . It is important to underline that the major part of this violence originates from the prisoners themselves and not, as might be supposed, from prison staff. In some cases, underpaid and demotivated prison staff may contribute to the violence, notably by condoning it. The overcrowding, which sometimes reaches 400% of capacity, particularly in remand prisons, further contributes to the climate of violence.
More relevant to the present issue than the actual official system is the internal hierarchy within the system. This complex power structure [12 ] is essentially the same throughout the countries of the former Soviet empire, with local variations. The system in itself is of Russian origin [13 ] , but since in Soviet times prisoners were transferred all over the territory of the Union it subsequently became the norm everywhere. The well-established internal hierarchy among prisoners is best described as a " caste system " . It is within this system that violence among groups of prisoners can be extreme, and can involve sexual practices that put large numbers of prisoners at high risk of catching STDs and HIV. [14 ]
The stratification among segments of the prison population is strictly horizontal [15 ] , prisoners belonging to one of four distinct groups. On top, and definitely in command, are the blatnye or " bosses " , professional criminals who form a well-structured, very well-organized clan, with laws of its own and duties as well. These bosses are the real power-brokers within the prison walls; the administration is well aware of and accepts this state of affairs, and indeed uses it to manage the prison population.
The second group, the " silent majority " directly under the bosses, is made up of the muzhiki ( " blokes or guys " ). These are the vast majority of prisoners, who are in for petty or sometimes more serious criminal offences but are not part of the crime milieu. These prisoners take part in prison work programmes, unlike the bosses who never do so. They provide the manpower in the prison, but have no say whatsoever in the internal hierarchy.
The third group comprises the kozly , the term referring to " collaborators " , that is, those who agree to work within the actual prison administration (office jobs, kitchen work, various other chores and duties). They are despised by bosses and blokes alike, but are generally left alone.
The last group of prisoners, at the bottom of the list, are the petukhi , the " untouchables " . These prisoners are veritable underdogs, shunned by all the oth ers, and are literally " untouchable " . They cannot share premises, work or even eat with other prisoners. They are of course housed apart, and for them to even brush against the sleeve of a boss may mean severe punishment or maiming. However, prisoners in this " caste " [16 ] are used by the bosses (and sometimes by others, even prison guards) as sex slaves. This type of contact is not seen as degrading, and can go far beyond what would in any case constitute rape in a Western context. In many cases, unspeakable forms of what can only be called sexual depravity are inflicted on these prisoners, for reasons of sexual gratification and sheer perversity. The law of silence prevents anyone from complaining or even mentioning this state of affairs to the prison administration, which in any case already knows about it and will do nothing.
As has been stated, HIV is not yet a major issue in most of these countries. The problem of prison violence, aggravated in many cases by extreme overcrowding and often abominable living conditions, is a very real one, and prison rape is an everyday reality for whole sectors of prisoners. No real epidemiological study of syphilis or other STDs has been carried out either, and such a step is unlikely in the near future. Even if the issue of condoms were an acceptable subject for discussion, which it definitely is not within what is a very " macho " prison culture (and this includes even the medical staff), it is hardly reasonable to suppose that their introduction would have any effect whatsoever in such a violent context. The real issues here are overcrowding [17 ] (which makes any classification and physical separation of prisoners impossible) and finding ways of curbing violence among prisoners.
B. The USA
At the other end of the spectrum the USA, with over 1,600,000 prisoners in Federal and State prisons, Count y jails and other holding facilities, also has a serious problem of prison violence. Here the actual extent of sexual violence has to some degree been documented [18 ] , a possible reason for this being that Americans tend to be more open about sexual matters than Europeans.
According to several studies conducted by health professionals and NGOs, the sexual abuse of male prisoners by other male prisoners is more than just a serious problem in US prisons. In maximum security prisons, where the majority of prisoners are in for very long terms and many of them have strictly nothing to lose, violence is a way of life. Various human rights groups have quite rightly begun to document this problem, as prison gang rape in the era of HIV can mean a death sentence for the victim. [19 ]
Although a great deal more information is available on the issue of sexual coercion in US prisons than elsewhere, it is still a topic which warrants further scrutiny. Presumably because such incidents are not supposed to happen at all, prison administrations are surprisingly lacking in any official statistics, even on prison rape. The stigma, for prisoners in this case, associated with being raped or coerced into sexual acts is certainly responsible for gross under-reporting of these acts to even well-meaning and " neutral " researchers. The issue is not only about violent rape, however.
Even in the more outspoken American society, where such topics as homosexual penetrative sex and fellatio scarcely raise an eyebrow among specialists, there is still uncertainty and some controversy relating to " circumstantial " homo-sexual practices in the prison setting. Many people, even medical researchers, still adhere to the viewpoint that coercive sexual practices in prisons amount in fact to homosexual activity, supposedly involving implicit consent. This notion is certainly erroneous and gives rise to confusion in the analysis of prison conditio ns. Others tend to see sexual practices between men in prisons merely as a form of substitute for the lack of heterosexual sex.
It is in this context that a distinction is drawn here, for the purposes of this paper, between, on the one hand, (unhyphenated) " homosexual " activity, i.e., practices between consenting " gay " men with homosexual gender preference, and, on the other hand, (hyphenated) " homo-sexual " activities, i.e., men having sex with other men for circumstantial reasons directly related, in this case, to the realities of prison life. These realities have to do with coercion and power for the " perpetrators " , and inversely with fear of rape and harrassment for the " perpetrated " .
Research in US prisons has shown that sexually coercive activities—not all involving actual rape—are widespread. There are many other more subtle forms of sexual coercion and subservience, both relating to the core issue of violence. In prisons all over the world, violence among prisoners almost always has a sexual component [20 ] . In the US, however, the problem has become so great that an NGO based in New York City, called " Stop Prisoner Rape " (SPR), specifically concerned with prisoner issues [21 ] , has produced in English and Spanish an informative brochure for male prisoners. It is available by mail, on the Internet or even in prison libraries, and describes in detail the issue of " protective pairing " , or " hooking up " , as it is known in prison jargon. New prisoners are advised to " pair up " with a stronger prisoner as soon as possible after entering prison so as to avoid gang rape and other forms of sexual violence. Prison culture respects this sort of " partnership " —which, however, implies sexual services rendered by the protected prisoner to his " man " .
The discussion on protective pairing is definitely beyond the scope of this b rief paper. In his paper on the subject the late Stephen Donaldson, former prisoner himself and prison rape victim, and former President of SPR, clearly states that there is no guarantee whatsoever that condoms can be useful in such situations. [22 ]
To Donaldson and others the utility of condoms in prisons is questionable [23 ] to such an extent that specific counselling is given, in minute detail, on how to make " paired " sexual behaviour as risk-free as possible in an unprotected (i.e. " no-way-to-get-him-to-use-a-condom " ) environment.
C. Sub-Saharan Africa
A discussion on HIV in African prisons would need an entire book in itself, and not just a few paragraphs in this paper. The aspect calling for examination here relates to the preconceived ideas that some many prison medical officers in these countries have about sexuality in prisons—and about the usefulness of condoms.
The confusion already mentioned between homosexual activities and circumstantial homo-sexual prison-related practices is a real issue in countries which have not—at least until recently—confronted the problem, and which have a real and justified concern about the spread of HIV. Prison medical authorities in these countries are following the " condoms for prisoners " controversy in the Western medical journals.
In one central African country the senior prison medical superintendent, when drawing up local " Guidelines on the management of HIV/AIDS in prisons " , stated:
" Sex among men is a recognized right in a number of Western countries (...). In countries where homosexuality is a recognized human right, the practice is rampant in prisons (...). There is a worry that this problem may be slowly spreading in Afr ican prisons " .
Here there is clearly confusion between true homosexual behaviour, for which European and other Western countries do indeed recommend the use of condoms, and coercive sexual practices that are directly related to the prison setting and violence.
The official distribution of condoms as a preventive measure inside a prison is an oxymoron in relation to African prisons, as in most of these countries any homosexual activity is a punishable offence carrying a sentence of up to eight years'imprisonment. The main point here is that circumstantial forms of sexual activity are mostly not recognized [24 ] . As long as coercive practices are ignored or simply neglected, concrete and sound proposals such as programmes for prisoners on " positive living " (education, advice on " risky behaviour " and pre-release counselling ) will not be effective.
D. Western Europe
Prisoners in Europe obviously do not form a homogenous population, to say the least. From discussions with prison medical officers, and from actual experience working within some of the systems, a general pattern of the different types of sexual activities in prisons can be traced. Unfortunately, for the reasons mentioned earlier, it is impossible to obtain any reliable figures. Researchers have tried giving out anonymous " questionnaires " , but invariably only a minority of the prisoners answer them, and there is no way of either controlling the veracity of their replies or finding out exactly why the rest of the prison population refuses to answer. Health professionals working in prisons can only be encouraged to pursue their efforts in this area. [25 ]
Rather than merely lamenting the lack of hard data and figures, it might be pref erable to consider the situations and relationships involved. Schematically, and to summarize an obviously complex issue, six different situations can be defined in which prisoners engage in sexual practices. [26 ]
(i) The case of violent rape (with its variant of " punishment " through rape [27 ] ) has already been mentioned.
The next three are all related to obtaining a product or service:
(ii) Sex in exchange for protection, essentially amounting to the same thing as American " protective pairing " , but in a less " institutionalized " way in Europe. Inmates without any other financial resources may have to " buy " protection from an individual or from a clan, paying with their bodies.
(iii) Sex for payment of debts (whether gambling or drug-related). Debts in prison are a very serious business: non-payment of debts can easily lead to severe beatings, maiming or even death. Prisoners without other resources will often have to pay with " sexual favours " .
(iv) Sex for money or other benefits. Prisoners without resources from prison work or from their families may well have to get money the only way they can. This situation obviously also applies, and even more so, to the poorer regions of the world. [28 ]
The final two categories are the only ones that actually involve " sexuality " as such, and are diametrically different:
(v) Heterosexual substitutional sex: this involves long-term inmates who pair up in " marriages " , not to obtain protection but to fulfil their sexual and even relational needs. As is the case for real-life heterosexual couples, these partnerships tend to imply complete trust, fidelity and even true affection. The actual " sex " is mentally heterosexual, prisoners reportedly " closing their eyes and thinking of their wive s " [29 ] . In this sort of relationship condoms are not used either. The element of trust involved and the fact that neither partner wants to risk being seen as a " homo " will keep these prisoners away from any condom dispenser.
(vi) Finally, there is the true homosexual relationship between two " gay " men who might have been using condoms outside prison, and who will be happy not to have to pay for them inside. [30 ]
These different categories of prisoners exist to varying degrees in many—possibly most— prison systems in Western Europe. For five out of the six, distributing condoms will not have any immediate effect, if at all. Even with redoubled education and information, it is difficult to see how making condoms readily available will reduce the incidence of unprotected sexual acts related to coercion. These acts, which have much more to do with power and dominance than with sexuality, are more than likely to short-circuit any condom dispensers in prisons, however " discreet " or " anonymous " they may be.
Sexual activity takes place in prisons in a variety of ways. Contrary to popular belief, not all of it involves " gang rape " and extreme violence, although in many countries such abuse is a not uncommon feature of daily prison life. The custodial setting, with its often very overcrowded premises and its specific environment where power and domination are everyday facts of life, lends itself particularly well to situations of coercion. This domination almost always has a sexual component. Subtle forms of " arm-twisting " and other forms of pressure which stem from complicated internal codes of conduct make large numbers of inmates dependent on other, more powerful, prisoners. " Sexual favours " are thus coaxed out of them. The weaker ones are forced to satisf y the stronger in order to obtain protection, pay their gambling or drug debts, or, in extreme cases, just to scrounge a living, obtaining what food and other material benefits they can. By their very nature, such " survival-driven " arrangements are highly unlikely to allow for any use of condoms.
The subject of such " partnerships " and the sexual servitude they imply is most often taboo, and it has been impossible for researchers to obtain any realistic statistics on these issues. Moreover, researchers that have attempted to study the problem invariably miss out one or other aspect of the " sex servitude " phenomenon.
Two forms of sexual activity that do not involve violence or coercion take place in prison settings. Heterosexual substitutional relationships ( " prison marriages " ) between perfectly " straight " individuals are apparently common among long-term prisoners. These couples do not use condoms either. The only prisoners that will use condoms (or might use them if they were available) are those in a true homosexual partnership. Condom dispensers will provide these prisoners with the condoms they were probably already using outside.
The issue of condoms for prisoners concerns only the tip of the very ugly iceberg of sexual violence in prisons. Sexual transmission of HIV infection (and other STDs for that matter) will not be eliminated by making condoms available. This very brief paper has tried to show how coercive sex among prisoners is a much broader issue than just " sex between gay prisoners " .
The realities of prison violence and prison promiscuity should be better documented if an effort is to be made to curb HIV transmission. This may prove extremely difficult, but it should be attempted, with all the situations mentioned here in mind. Furthermore, before any form of health education can be effective, the overall problem of ove rcrowding in prisons has to be solved. Only then will it be possible to sort out the various categories of prisoners and to implement programmes designed to promote " positive living " and a " healthy prison life " .
1. In 1996, ICRC teams visited over 137,000 prisoners in more than 40 countries.
2. See " Sexual Torture of Male Victims" H. van Tienhoven in " Torture " Vol 3, 1993
3. With the exception of (heterosexual) conjugal visits, allowed in some countries.
4. In the Prisons Service of England and Wales, instructions from the Health Care Department in 1995 advised prison doctors that non-provision of condoms might arguably be considered a failure in the duty of care, thereby entailing legal liability if a prisoner having contracted HIV within the service (through sexual contact) went ahead and sued the Service.
5. In the Geneva remand prison, condom dispensers are found sitting on the doctor's desk like ordinary candy jars. Remand prisoners can take as many as they like, no questions asked. On the other hand, prisoners can of course raise the issue with the doctor in complete confidentiality if they so choose.
6. The use of a hyphen is deliberate and will be explained further on.
7. Interview with the Netherlands Medical Inspector for Prisons, September 1997.
8. There is a further controversy on the type of condoms issued. The routine type (normally used for heterosexual sex) are widely believed to be unreliable, and the medical services are trying to obtain " homosexual " (i.e. more sturdy) condoms instead.
9. Discussions with local prison medical officers and with experts from the WHO.
10. The actual Russian term for " prison " only refers to one specific form of establishment. Remand prisons are called " isolators " ; sentenced prisoners go to " colonies " . " Prisons " per se are disciplinary places for hardened criminals, recidivists and other serious cases.11. Most notably in documents produced by the NGO specifically working with prisons in Russia and in the countries of the former Soviet Union : Moscow Center for Prison Reform (
: see In Search of a Solution , MCPR 1996)
12. What follows relates to the " colonies " , where the majority of prisoners are held. " Isolators " are more tightly controlled by the authorities, but are even more violent because it is there that overcrowding reaches extremes.
13. It is in fact a direct inheritance from the post-Stalinist period, after Khrushchev freed the vast majority of his predecessor's Gulag prisoners, and criminal gangs were allowed to build up power within the prisons, essentially to assist the authorities in control.
14. It is impossible to know what the prevalence of HIV infection may be within the prison populations of most of these countries, but with prostitution and intravenous drug use on the rise in Moscow and other capitals, the problem may be just around the corner.
15. Prisoners can " fall " into a lower group, but never, ever, come back into a higher one.
16. Which includes almost by definition all homosexuals and sex offenders, as well as those regarded as outcasts or underdogs for any reason whatsoever.
17. The issue relates not only to lack of space, but also to slow or corrupted judicial procedures, over-sentencing for petty crimes, and even over-staying (for reasons of administrative incompetence, corruption or both) all of which contribute to the prison population inflation.
18. A recent instructive study : Struckman-Johnson et al., " Sexual coercion reported by men and women in prison " , Journal of Sex Research, Vol. 33, No. 1, 1996. See also the very informative : " Male Rape : A Casebook of Sexual Agressions" A. Scacco, AMS Press N.Y. 1982 and " Men behind Bars : Sexual exploitation in Prison " , Wooden & P arker, Plenum Press, N.Y. also 1982. These texts, though from the eighties, are still, acording to researchers very relevant to the situation today, made even worse by the ever rising prison population.
19. Human Rights Watch, based in NY, after having documented violence against female prisoners in the US, is now working on a comprehensive study on [male ] prison violence.
20. To give an example, punishment beatings ending with a broomstick up the rectum have been reported in many different countries.
21. Based in New York City ( http://www.igc.apc.org/spr/ ). Another organisation providing advice and material on sexual assault in confinement is the " Safer Society Press " , in Vermont (PO Box 340, Brandon VT)
22. " Hooking Up : Protective Pairing for Punks " , St. Donaldsen, S.P.R. see footnote 21.
23. Even in the United States prison system, where the issue of HIV and AIDS is openly discussed and of primary concern to all .
24. In one central African country, however, prison medical authorities did acknowledge that " there is a big worry about circumstantial man-to-man sexuality " .
25. One commendable effort was made by a French team of researchers within the French prison system. It was, however, impossible for them to get permission to interview prisoners inside the prisons, and all their interviews were with former inmates and prison staff. See Sexualités et Violences en Prison , Welzer-Lang et al, Observatoire International des Prisons, Lyon 1996.
26. Findings based on interviews with prison social workers and doctors, and also from prisoners.
27. This often involves sex offenders, seen by other prisoners as " deserving it " .
28. In some of the poorer prison settings, even food may have to be obtained in this way so as to avoid malnutrition.
29. Or their girlfriends, or the latest top models or whoever, but definitely female.
30. This is true for the majority of the less violent European prisons. In US and other violent prisons, recognized homosexuals are victimized. Considered fair game for sexual harassment and targeted for gang rape, they will in this case have little or no chance of convincing their tormentors to use condoms. Prisoners seem to be aware of the (partially true) fact that the " perpetrator " is at lesser risk of contracting HIV than the " perpetrated " .
Ref. LG 1997-146-ENG