PROVIDENCE, R.I. [Brown University] —Even behind bars it can be a hard question to raise, but new research suggests that asking female inmates whether they have a history of exchanging sex for money or drugs can help identify whether they are at heightened risk for serious health consequences.

The study led by Dr. Amanda Noska, assistant professor of medicine in the Warren Alpert Medical School of Brown University, and Dr. Jennifer Clarke, medical director of the Rhode Island Department of Corrections (RIDOC), asked the question of 257 women incarcerated in Rhode Island. They found that 68, or more than 1 in 4, had engaged in sex exchange. Noska, who treats RIDOC patients and is also affiliated with the Providence Veterans Affairs Medical Center and the Miriam Hospital, said she was surprised the prevalence was so high, but there are very few other estimates in the research literature.

“No study has yet evaluated the variable of lifetime history of sex exchange among incarcerated women as a clinical marker for social and structural vulnerability within the community,” Noska and her colleagues wrote in the Journal of Health Care for the Poor and Underserved.

The findings by Noska and Clarke, associate professor of medicine and obstetrics and gynecology, show that assessing lifetime history of sex exchange could alert prison health officials to significant likelihoods of several problems in a female inmate’s life, even compared to their fellow inmates.

After adjusting for potential confounding factors, Noska and her team found that compared to incarcerated women who had not engaged in sex exchange, women who did were 2.2 times as likely to have suffered physical abuse, 2.5 times as likely to have used injection drugs, 2.9 times as likely to have two or more sexually transmitted infections, and 8.3 times as likely to have had 10 or more sexual partners. They were also only 30 percent as likely as women who had not engaged in sex exchange to have held a job for a year or more prior to incarceration.

The study also found that significantly greater proportions of women who engaged in sex exchange had unstable housing before incarceration and were depressed. On average they had been using drugs for almost twice as long. Engaging in sex exchange, Noska said, may be a signal that some women have become victims of structural inequities throughout their lifetime.

Women in the study were between the ages of 18 and 35 between March 2009 and July 2011 when the data were collected.

A question worth asking

Noska has provided care in prisons since her medical residency, but she has not always asked women about sex exchange.

“As a clinical provider the most important thing is a patient’s trust – minimizing stigma in a clinical encounter so that people feel comfortable with you and that they trust that you are trying to take good care of them,” Noska said. “Sometimes it’s difficult to ask questions that don’t appear to have an immediate clinical purpose. In this scenario, a lot of providers might hesitate.”

They shouldn’t hesitate, she said.

“The point of this paper is that there are many correlations between sex exchange and other risk factors,” she said. “When done appropriately and with compassion and with a focused intention in mind we actually should probably be asking about this.”

In addition to Noska and Clarke, the study’s other authors are Mary Roberts, Dr. Carolyn Sufrin, L.A.R. Stein, Dr. Curt Beckwith, Dr. Josiah Rich and Emily Dauria.

Through the Lifespan/Tufts/Brown Center for AIDS Research and the National Institute of Drug Abuse, the National Institutes of Health funded the study (grants: P30AI42853, R25DA013582).