Current Trauma Reports (2022) 8:172–178

https://doi.org/10.1007/s40719-022-00234-4

INTENTIONAL VIOLENCE (S BONNE AND M CRANDALL, SECTION EDITORS)

Violence in Incarcerated Populations: a Review of the Literature

Ayana Worthey1 · Arielle Thomas2,3 · Caitlin Jones1 · Adil Abuzeid1 · Cassandra Q. White4

Accepted: 3 June 2022 / Published online: 27 July 2022

© The Author(s), under exclusive licence to Springer Nature Switzerland AG 2022

Abstract
Purpose of Review To provide an overview of the current research surrounding violence in prison populations.
Recent Findings It has been a long-held misconception that race plays a factor in the propensity to commit violence
leading to the higher rates of incarceration. On review of recent data, exposure to violence and socioeconomic sta-
tus play a big part in not only how a person’s path leads to incarceration, but also to the continuation of the cycle of
violence. The lack of effective interventions in the prison and jail environments also contributes to the incidence of
violence in this patient population. Furthermore, this lack of intervention leads to the development, or worsening in
some cases, of medical and psychiatric problems in this group.
Summary Incarcerated populations are at high risk for physical and sexual assault from other inmates as well as from
staff. The consequence of this environment exacerbates pre-existing physical and mental conditions. Further research
must be done into evidence-based interventions that address these overwhelming disparities.

Keywords Violence · Incarcerated populations · Prisoners · Prison · Penal institutions

Introduction to affect a third of men and a fourth of women behind

bars. Beyond the long-term physical implications of this
There are almost 2 million individuals who are incarcer- problem, there is substantial evidence that incarcerated
ated in the USA in state and federal prisons or jails [1]. persons suffer from higher rates of psychiatric conditions
Violence in prisons is pervasive and has been estimated than the general population, increased risk of mortality
on release, and increased risk of recidivism associated
with poor health [2–4]. Furthermore, special populations
This article is part of the Topical collection on Intentional Violence such as LGBTQ + , juvenile populations, and females
are at increased risk of experiencing violence, physical
* Cassandra Q. White
cassandra.white@jax.ufl.edu or sexual, while incarcerated [5, 6]. Though the USA
releases regular reports on mortality and sexual victimi-
Ayana Worthey
aworthey@augusta.edu zation in prisons and jails, there has not been a recent full
review of violence in prison populations.
Arielle Thomas
athomas@facs.org To better examine the trauma experienced by incarcer-
ated persons within the USA, the authors consider the fol-
Caitlin Jones
caijones@augusta.edu lowing four specific categories: homicide, suicide, physical
assault, and sexual assault. While these categories are not
Adil Abuzeid
aabuzeid@augusta.edu conclusive, they provide a broad framework for discussion.
The existing data on trauma experienced by incarcerated
1
Medical College of Georgia, Augusta University, Augusta, persons is often sparse or outdated with cited sources fre-
GA, USA quently being government-issued reports. Finally, special
2
Feinberg School of Medicine, Northwestern University, populations such as juvenile and LGBTQ populations are
Chicago, IL, USA at increased risk of experiencing violence due to their vul-
3
American College of Surgeons, Chicago, IL, USA nerable status.
4
University of Florida College of Medicine – Jacksonville,
655 West 8th Street, Jacksonville, FL 32211, USA
Current Trauma Reports (2022) 8:172–178 173

Homicide [7]. As of 2019, the unadjusted suicide rate for the US

population is 17.97 per 100,000 residents, which is simi-
According to Mortality in State and Federal Prisons, lar to the unadjusted rate in 2018 [11]. At the time of this
2001–2018—Statistical Tables, homicides accounted for publication, there are no updated statistics regarding the
approximately 2% of state and 3% of federal inmate deaths prison population.
during this time period at a rate of 10 per 100,000 state Similar to inmate homicide, suicidality in prisons dis-
prisoners and 8 per 100,000 federal prisoners by 2018 [7]. proportionately affects males compared to females (17 per
These rates more than double the US homicide rate of 4 100,000 prisoners vs. 13 per 100,000 prisoners) [7]. Fur-
per 100,000 residents after adjustment for age, sex, and thermore, inmate death by suicide was most common among
race/ethnicity. Homicides include the following: homicides ages 25–44 (60%) [7]. The racial breakdown of inmate
committed by other inmates, incidental to the staff use of suicide victims mirrored that of homicide: White inmates
force, and resulting from assaults sustained prior to incar- were found to be 3 times more likely to commit suicide than
ceration [7]. Of note, these statistics exclude deaths that Black inmates and 4 times more likely than Latino inmates
occurred in privately owned federal facilities as the Bureau [7]. Finally, the suicide rate in local jails (45 per 100,000
of Prisons (BOP) submitted limited aggregated data to the inmates) was over double the rate in state prisons (17 per
Bureau of Justice (BJS) [7]. Males are overrepresented as 100,000 inmates) [12].
homicide victims in state prisons with an average annual Risk factors for victims of suicide inside correctional
rate of 6 per 100,000 male prisoners vs. < 1 per 100,000 facilities were male gender, prior history of substance use,
female prisoners. When evaluated by race, White inmates history of traumatic brain injury, single-occupancy cells
constitute approximately 44.6% of homicide deaths while and/or isolation, non-suicidal self-injury, prior history of
Black and Latino inmates constitute 35.5% and 16.9% of attempted suicide, violent offense as reason for incarcera-
state inmate homicide victims respectively. Interestingly, tion, childhood adverse events, and diagnosed history of
Blacks and Latinos comprise a higher percentage of total mental illness [13–16]. Longer sentences correlated with
inmates at the state level compared to Whites per the bul- higher suicide risk [14]; however, in a 2020 study by Dixon
letin Prisoners in 2015 [8]. Finally, state inmates were most et al., more than half of suicide victims were incarcerated
likely to die due to homicide if they were between 25 and less than 1 week and a quarter was incarcerated for less than
34 years of age, and least likely to be a homicide victim 24 h [17]. More than 90% of incarcerated suicide victims
if less than 18 years of age. Death by homicide continues were in a cell at the time of fatal injury and 1/3 of suicides
to decline in the later decades of life and is superseded by occurred between noon and 6 pm with an overrepresenta-
death due to illness. tion of individuals who were in single-occupancy cells or in
Reidy et al. and Reidy and Sorensen et al. describe segregation [17].
risk factors for homicide perpetrators as males who were
incarcerated for a violent crime typically serving a lengthy
sentence (almost 50% of the perpetrators were serving a Physical Assault
sentence of 30 years or more) [9, 10]. The most common
location for homicides is inmates’ cells (44%), followed There is a paucity of data regarding the incidence of physi-
by common areas (19%), and the prison yard (16%), and cal assault within prisons in the USA. Persons currently
about half of the victims were stabbed to death [10]. Hom- incarcerated may withhold reporting of violent offenses for
icide perpetrators were more likely to commit rule viola- a litany of reasons, such as personal safety while still incar-
tions, have a prior criminal record, and have institutional cerated. The rate of violence-related injuries is estimated at
maladjustment than other inmates [10]. 15,721 per 100,000 inmates with male inmates being twice
as likely to be violently injured than females (16,252 per
100,000 males vs. 8397 per 100,000 females) [18]. Physical
assault can be defined as inmate-on-inmate, inmate-on-staff,
Suicide or staff-on-inmate depending on the aggressor [19]. A 2009
survey of 6964 male general population inmates aged 18
Suicide is a leading non-medical cause of death for or older at 12 male adult prisons operated by a single state
inmates with the rate increasing by 85% by the end of reported that nearly 32% of these inmates sustained at least
the study period in 2018 according to the BJS [7]. By one physical assault over a 6-month period [19]. Physical
2018, suicide accounted for 26 per 100,000 prisoners and assault victims were more likely to be Black, aged between
19 per 100,000 prisoners at the state and federal levels 30 and 40 years, and serving sentences greater than 5 years
respectively, the highest rate since the report’s inception in length [19]. The most common types of inmate-on-inmate
174 Current Trauma Reports (2022) 8:172–178

assaults in this study were as follows: harm with a knife addressing, and preventing sexual violence in jails and pris-
or “shank”; a makeshift knife often made of metal scraps ons, as well as redefining rape in a more gender-inclusive
that are sharpened (39.2%); being slapped, kicked, or bitten way [23]. Once an allegation has been made, PREA requires
(16.9%); or hit with an object (9.2%). The most common prison authorities to perform an investigation, after which
types of staff-on-inmate physical assaults were threat of the claim is either found to be a “substantiated allegation,”
harm or harm with a knife or shank (24.6%); being slapped, meaning the event was determined to have occurred based
kicked, or bitten (20.4%); and being “beat up” (13.9%). on available evidence; an “unfounded allegation,” meaning
Greater than 40% of victims of inmate-on-inmate assaults the event did not occur; or an “unsubstantiated allegation,”
knew their attacker; greater than 65% of assault perpetrators meaning there was insufficient evidence to determine if an
were known or self-purported gang members [19]. Notably, act of sexual victimization had occurred [24].
more than three-quarters of inmate-on-inmate assaults were The BJS considers sexual violence in two broad catego-
witnessed by other inmates, but not by prison staff. This ries of sexual victimization: inmate-on-inmate and staff-
illuminates a likely contributing factor to the lack of report- on-inmate. This can then be broken down into consensual,
ing and investigation of inmate-on-inmate assaults due to nonconsensual, bartering, and coercion [25]. The BJS Spe-
absence of staff corroboration during the investigation and cial Report entitled Sexual Victimization Reported by Adult
lack of accountability for guilty parties [19]. Other risk fac- Correctional Authorities, 2012–15 revealed that investiga-
tors for perpetrating violent injury include a personal history tions were performed for 28,507 of the 30,590 inmate-on-
of hostility and aggressiveness, physical impairment, prior inmate allegations (93%), and 32,809 of the 36,578 staff-
history of violent offense, history of violent victimization on-inmate allegations (90%) during the 4-year period. Only
prior to or during incarceration, recent history of mental 8%, or 5187, of these completed investigations were found
health treatment, overcrowding, incarceration in a maximum to be “substantiated” [24] Between 2011 and 2015, a 180%
security prison, and history of delusions or hallucination in increase in reporting was seen in federal and state prisons
the last year [18, 20]. and jails with similar trends of increased reporting seen in
Pre-incarceration factors appear to contribute to an military-run facilities and immigration detention centers
inmate’s propensity to either commit a violent act against [24]. Notably, up to 58% of all reported incidents of sexual
another or be a victim [21]. Prisoners with a higher socioec- victimization were perpetrated by prison and jail staff [24].
onomic status, more education, or a history of non-criminal Though there are few recent studies that examine the
employment prior to incarceration were less likely to commit risk factors for perpetrating sexual misconduct, main pre-
offenses against other inmates. While female prisoners have dictors in the literature for inmate-on-inmate infractions are
the same pre-incarceration risk factors, it has been shown increased number of previous incarcerations, longer length
that females are less likely to offend if they have children, of time served, history of committing a violent offense,
while family status does not appear to have this same effect previous sexual victimization, presence in a closed secu-
on males [21]. rity facility, and younger age [25, 26]. Individuals at higher
Lastly, aggressors committing infractions (violent and risk for being sexual assault victims are female, members of
non-violent) within the prison system also have a higher rate the LGBTQ + community, have a history of mental illness,
of prior violence exposure compared to the general popula- have a college degree, or have a history of childhood sexual
tion [22]. In a study performed by Steiner and Meade, it abuse [5, 27, 28]. Physical assault and sexual assault are
was noted that 71% of the state inmate sample were exposed intricately linked with 44% of victims of inmate-on-inmate
to violence [21]. Of those exposed to violence, 39% were sexual victimization and were accompanied by physical
abused as children, while close to 50% were abused as assault or threat of force [29]. Furthermore, 12% of inmates
adults. Additionally, 70% were physically abused while experienced coercion of some kind, and 5% of incidents
10% were sexually assaulted [22]. While bivariate analysis occurred in exchange for bribes of drugs or contraband,
noted that almost all measures of violence exposure led to or by blackmail [29]. Finally, the consequences of sexual
performing some type of infraction, multivariate analysis misconduct are significant with about 18% of all inmate-
showed that those who were abused as children were more on-inmate sexual victimization and 28% of nonconsensual
likely to commit assaults and other infractions [21]. victimization resulting in injury.
Staff-on-inmate sexual victimization includes a range of
acts that range from sexual harassment, privacy violations,
Sexual Assault to inappropriate touching and invasive prisoner pat-downs.
The majority of reported cases are committed by correc-
Much of our knowledge regarding sexual assault within pris- tional officers [5, 28]. A hallmark of staff sexual misconduct
ons stems from the Prison Rape Elimination Act (PREA). is coercion, which has been found to include exchange of
Passed in 2003, PREA developed standards for reporting, sexual acts for resources, protection from inmate-on-inmate
Current Trauma Reports (2022) 8:172–178 175

violence, and fear of physical force [28]. Physical force and the existing prison subcultures. As a result, they can engage
pressure or abuse of power were identified in 20% of inci- with negative methods of coping such as threats, verbal chal-
dents involving male staff, compared to 1% of incidents lenges, invasion of personal space, and more [45].
involving female staff [29]. However, 54% of staff-on-inmate Behavioral maladjustments from inmates who suffer from
sexual misconduct and 26% of sexual harassment in prisons mental illness are seen as weak and easy targets by aggres-
were committed by females while 80% of staff perpetrators sive inmates, and thus have a higher risk of suffering from
were male in local jails [29]. property victimization [20]. Those inmates suffering from
Finally, African American males have long been con- mental illnesses associated with paranoia, or hallucinations
sidered to be more likely to perpetrate inmate-on-inmate of violence within their facility, may perpetrate violence.
sexual assault based on outdated studies looking at sexual Mental illness is also associated with suicidal behavior and
misconduct [30, 31] and misconduct as a whole [32–34]. non-suicidal self-harm during and after incarceration [13,
More recent studies have not found this to be true, either 14, 46]. Substance abuse compounds these effects and can
finding other races and ethnicities to be more likely to per- worsen the prognosis of an inmate mental health disorder
petrate violence, or finding no association between race and [44]. Those who are mentally ill are also more likely than
misconduct at all [34–36]. The differing impact of race on their fellow inmates to be punished by solitary confinement
misconduct (sexual or physical) implies that it may not be [41]. This exacerbates the incarcerated individual’s inability
race but another mediating variable such as socioeconomic to adapt to their environment, creating the potential for a
status, regional characteristics of the facility, or personal vicious cycle. The consequences of poor physical and mental
background that may be influencing results. health during incarceration lead to an increased risk in reof-
fending and recidivism [47].

Mental and Physical Consequences Special Populations

of Incarceration
Juveniles
The unique environment of prison contributes significantly
to development, or exacerbation, of physical and mental Rates of sexual victimization are higher among incarcer-
health diagnoses in prisoners. Incarcerated individuals are ated juveniles than incarcerated adults, though rates among
more likely to have worse physical conditions such as infec- juveniles have decreased since the initiation of the National
tious diseases, obesity, cardiovascular disease, hyperten- Survey of Youth in Custody in 2009 [48]. Historically,
sion, and cancer [37–40]. Incarceration is associated with female youth experience increased rates of sexual assault
an increased risk of premature mortality with a greater risk and victimization [6, 49]; however, this gap has decreased
for women [4]. due to increased reporting by the male youth [49]. In one
The prevalence of severe mental disorders (defined as study by Ahlin et al., 8659 detained youth from 326 state
mental disorders that interfere with an area of social func- and privately owned facilities in the USA were randomly
tioning such as depression, panic disorder, bipolar disorder, selected to participate in a survey to assess the relationship
and more) among prisoners is about 2–4 times more than between individual characteristics and experiences with
the general population [41]. Deinstitutionalization of the sexual assault during periods of detention [49]. Juveniles
psychiatric healthcare system has resulted in 10 times more who were new to the facility, who identified as LGBTQ + ,
individuals with serious mental illness who are incarcer- had experienced previous assault, or were part of a gang
ated rather than in a mental health facility [42]. Screening were more likely to be sexually assaulted or victimized while
for mental disorders is not consistent on intake at correc- incarcerated [49]. Facilities with a higher prevalence of gang
tional facilities, and it is difficult to assess how many of fights and limited staff to monitor activities have a higher
those incarcerated had mental disease before incarceration incidence of sexual assault [50]. Rates are higher in facili-
versus developing it secondary to the social climate of the ties where inmates do not report sexual activity for various
prison system [43]. Disorders are frequently not identified, reasons: fear of the youth involved, fear of being punished by
and when diagnosed are typically under-treated. Prevalence staff or not believed, shame, or the belief that staff would not
of psychotic illness in both men and women is estimated investigate or the perpetrating inmate punished [51].
at 4%, major depression 10% among men and 14% among Juveniles that are incarcerated suffer severe socioeco-
women, and substance abuse 10–48% among men and nomic and psychosocial ramifications. They experience a
30–60% among women [44]. Inmates arriving to correc- disruption in their education (40% additionally have a learn-
tional facilities with pre-existing mental disorders typically ing disability) with a decreased chance that they will return
have a difficult time adapting to their new environment and to school or remain in the workforce, increasing the risk of
176 Current Trauma Reports (2022) 8:172–178

having lower earnings in the future. Rather than allowing housing relocation, and voluntary solitary confinement
for “aging” out of delinquency, as the authors Holman et al. [58]. Solitary confinement is the most frequently used as
suggest, the incarceration environment reinforces delinquent it is a means of protection from harassment related to their
behavior and negative influences [52]. Among this popula- sexuality, sexual abuse by staff, protection from gangs, and
tion, there is increased risk of poor parental relationships protection from other prisoners forcing them to sell their
moving forward, membership in a gang, and carrying a bodies. Eighty-five percent reported time in solitary con-
weapon. Juveniles that are incarcerated rather than serving finement on the Black and Pink survey with 50% spending
in the community for delinquent behavior have increased two or more years in this setting [58]. Extended time in
likelihood of recidivism and incarceration as adults [52]. solitary further compounds the disproportionate mental
Suicide is the second leading cause of death in youth aged health problems this population already experiences, exac-
10 to 24 years old, accounting for almost 20% of deaths. For erbating adverse outcomes related to mental health [57].
incarcerated youth, the suicide rate is 2 to 3 times higher
compared to the general population [53]. Risk factors for
youth suicide include being incarcerated, being incarcerated Immigrants
in adult facilities, previous victimization, mental illness,
and facility characteristics such as separation from family/ Immigrants, for the purposes of this discussion, refer to
friends, extended periods of isolation, or crowded living refugees and asylum seekers. While there is data regarding
spaces [53, 54]. their experiences in their respective countries and travel,
there is not much regarding their experiences in the immi-
Lesbian, Gay, Bisexual, Transgender, and Queer gration detention centers.
(LGBTQ +)

The LGBTQ + population are disproportionally repre-

sented in the number of incarcerated people in the USA Conclusion
[55, 56]. According to data reported in the National Inmate
Survey (NIS), people who identified as being part of the Violence in prison is a substantial problem that is under-
LGBTQ + community were three times more likely to be researched compared to the percent of the proportion of
incarcerated compared to the general population despite only the US population that is incarcerated. Pre-incarceration
making up between 2 and 6% of the population [55, 57]. Dis- exposure to any form of violence and lower socioeconomic
crimination faced by this group increases their risk of food status factor heavily on whether or not a person experi-
and housing instability leading to a higher rate of behaviors ences violence when incarcerated. This is potentiated by
(drug trafficking and sex work) that result in incarceration the fact that over half of inmate violence is perpetrated
[56]. When incarcerated, the LGBTQ + population is six by the staff within the prison system. Presently, there is
times more likely to be sexually assaulted with higher rates no data to show prevention efforts after incarceration to
of victimization from staff and other inmates [55, 57, 58]. decrease the likelihood of these events. Having PREA in
In a survey of LGBTQ + identifying prisoners performed place is a good start; however, it appears that little has
by the Black and Pink organization in 2015, 100% reported been done with this data. Given the substantial mental
experiencing strip searches on a regular basis and 77% expe- and physical consequences that exposure to this type of
rienced discrimination based on sexual orientation, 83% ver- violence causes, a focus on evidence-based interventions
bal harassment, 52% unwanted touching, 31% sexual assault (before, during, and after incarceration) is imperative in
or rape, and 64% physical assault [58]. Seventy-six percent an attempt to break the cycle of violence.
reported being intentionally placed in situations at high risk
for physical or sexual assault by staff. Of the 68% of inmates
endorsing a romantic relationship while incarcerated, 47% Data availability Upon request.
report intimate partner abuse prior to incarceration [58].
Code Availability n/a.
The increased risk of victimization in this sexual and
gender minority has led them to feel that they have limited
options for help [58]. This is particularly true in the gender
Declarations
minority, who are placed in prisons corresponding to their Conflict of Interest All of the authors declare that they have no con-
gender at the time of birth [55, 56]. Stigma placed on these flicts of interest.
inmates by heterosexual inmates leads to increased rates of
harassment, physical violence, and sexual violence [59].
Avenues of escape often include sexual favors, self-harm,
Current Trauma Reports (2022) 8:172–178 177

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