Abstract After objections surfaced following a call for papers on “Prisoner Health,” the editors of Epidemiologic Reviews decided to rename this year’s volume “Incarceration and Health.” In this commentary, we trace the origins of person-first language and explain why using appropriate terms in correctional health, including correctional health epidemiology, matters. We discuss the potential consequences of person-first language for justice-involved individuals and how inclusive language might affect the social, emotional, and physical well-being of individuals, families, and communities. Future directions may include measuring health outcomes when language is systematically changed. The barriers that thwart successful reentry may wane when dehumanizing language disappears. incarceration, jail, person-first language, prison, stigma In 2017, we became aware of a call for papers for the 2018 issue of the journal Epidemiologic Reviews, which would focus on the topic of “Prisoner Health.” As researchers studying public health with a specific emphasis on improving the health of incarcerated populations who disproportionately experience health burdens, we thought the theme sounded off-key. For the past few years, in keeping with the requests of persons who have been incarcerated in the United States, many correctional think tanks (1) and advocates (2) have tried to incorporate “person-first” language. The nonprofit Osborne Association recently established a humanizing language project and developed a useful guide for referring to persons in custody (3). Following this guidance, we aim to refrain from using the word prisoner, as well as the terms offender, inmate, detainee, convict, felon, parolee, probationer, releasee, ex-prisoner, ex-offender, etc.—any terms that define a person by a place or standing within the criminal justice system. A recent letter in the Journal of the American Medical Association by Lorie S. Goshin (4) pointed out how such terms run contrary to the rules of the American Medical Association Manual of Style by promoting overgeneralizations about people who have been touched by the correctional system. This year, organizers of a leading conference on correctional health research, the Academic and Health Policy Conference on Correctional Healthcare, for the first time insisted in the call for abstracts that authors not use stigmatizing language. The call included a glossary of suggested terms (5). We are joining effective social moments that are aligning to remove stigma from impoverished communities affected by the dominant culture that could control their existence with labels that might disempower them politically and economically. Labels and language matter. Language has the power to condemn or redeem, and words reflect our values and beliefs as clinicians, scholars, and members of the community. Labels have less power when collectively we stop using them. Person-first language is the foundation for clinical practice that fosters shared decision-making, human dignity, and hope. It has gained traction in the fields of psychology (6) and social work (7) and has been deemed important in moving substance use disorder and treatment research toward a more recovery-oriented model (8, 9). HISTORICAL BACKGROUND The origins of person-first language come from disability advocacy in the 1970s and 1980s. It was then that people with disabilities first started to call for an eradication of labels that defined an individual by their impairment or difference. Disability advocates began to call for linguistic representation that recognized that people are more than their disabilities. Thus, terms like “people with disabilities,” “person with vision impairment,” “individual who uses a wheelchair,” and “person with intellectual disability” arose. This push emerged in the wake of other civil rights–related efforts to ensure the communities of concern determined the preferred language used to discuss them. People with disabilities wanted others, including care providers, to demonstrate a recognition that people with disabilities are complex individuals with multiple important identity features (10, 11). Although there are some disability-related subgroups that prefer identity-first language, such as some in the deaf community (12) and the autism community (13, 14), who may find their differentness as central to their identity formation, on the whole person-first language remains an important feature of disability advocacy. As Goshin’s commentary demonstrates, the transformation toward person-first language has been slower in medicine. Apparently, epidemiology has just now taken notice. The terms “persons living with HIV” and “persons who inject drugs” have recently become standard in the medical literature so that the acronymns PLWH and PWID rarely need explanation. Efforts to characterize and improve the health of people in correctional systems must keep pace. As these communities attest, language has moral weight. Labels can serve to “other” people and signify a lower social position based on a conflation of a person with a socially devalued trait. Thus, it is critical to recognize and respect the humanity in individuals who have experienced incarceration by choosing to use and promote the language this community prefers. APPLYING PERSON-FRIST LANGUAGE TO CORRECTIONAL HEALTH The health of persons who pass through a jail in a year or are confined to a prison influences the health of the community as a whole. In recent years, approximately 10 million individuals in the United States spent at least part of the year in a jail or prison (15). On a given day in 2015, a total of 6.7 million persons were under the supervision of the criminal justice system; one-third were in a locked facility, and two-thirds were on parole or probation in the community (16). Even if “only” 3% of US adults are under supervision today, the proportion of affected individuals who pass through a confined environment each year is enough to sway some epidemics. For example, 30% of persons with hepatitis C have spent part of a year incarcerated (17). Access to treatment while incarcerated, which is currently rare (18), could transform our nation’s ability to eliminate an eminently curable disease (19, 20). Although the United States leads the world in its incarceration rates, other countries also have rising levels of confinement (21). Most often, experience with the criminal justice system is not a salubrious one; health rarely improves. The standardized mortality ratio for persons ever incarcerated compared with the general population is less than 1 (22). However, the exact toll that incarceration imposes on the health of those passing through is unknown. The chronic underfunding of correctional health research contributes to our ignorance (23). Arcane regulations, found in 45 CFR 46 Subpart C, stymie attempts to conduct well-designed studies (24). The regulation allows demonstration projects, but to conduct a randomized clinical trial using a placebo control, the Secretary of the Department of Health and Human Services must personally approve the protocol, and that can take place only after convening a panel of experts (25, 26). With so many hinderances to investigating how public health interventions can improve the health status of persons who are incarcerated, we should not add insult to injury by using dehumanizing language. We acknowledge that language alone is insufficient to shift the pervasive stigma that continues to grip individuals who have spent time incarcerated. These populations encounter short- and long-term barriers to employment, housing, financial aid, and civic participation (27), and evidence has shown that it is the dichotomous experience of ever being incarcerated that matters more than its dosage (28). Although efforts to adjust the language we use in describing the populations we serve are important, these initiatives must complement more structural actions, including enhancing access to healthcare in correctional settings, supporting reentry into the community, and ultimately reforming the prison-industrial complex as a whole. MOVING FORWARD Nonetheless, language is a fundamental place to begin to erode many decades of stigma. Epidemiologic studies inform the clinical guidance that providers use to best serve their patient populations and establish the extent and distribution of health problems for public health practitioners to take action. Future research may include measurement of health outcomes when language is systematically changed. Policymakers increasingly turn to research evidence to guide budget and policy decisions. It is clear that epidemiology represents the headstream from which many activities to address population health flow; thus, it stands to reason that we should hold ourselves to the highest standard when discussing the health of some of the most marginalized members in our society. Ostensibly, research on correctional health stems from a fundamental belief that people are capable of positive change after involvement with the criminal justice system. The words that fill our manuscripts and that are ultimately consumed by students, researchers, and providers should align with this belief. Conclusion Inclusive language is designed to improve the social, emotional, and physical well-being of families and communities. Areas of future research may include measuring health outcomes when language is systematically changed. The barriers that thwart successful reentry may be lessened when further marginalization is removed and humanity is restored. I don’t like labels like felon, offender, ex-prisoner, or former prisoner. I am a person who served time in prison many years ago, and that experience doesn’t identify all of who I am. —First author ACKNOWLEDGMENTS Author affiliations: Department of Psychiatry, School of Medicine & Dentistry, University of Rochester, Rochester, New York (Precious S. Bedell); Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia (Anne C. Spaulding, Marvin So); Department of Medicine, Morehouse School of Medicine, Atlanta, Georgia (Anne C. Spaulding); and Center for the Study of Human Health, Emory College of Arts and Sciences, Emory University, Atlanta, Georgia (Jennifer C. Sarrett). P.S.B. and A.C.S. contributed equally to this work. We wish to thank Carolyn Mackey for help in preparing this article for publication. Conflict of interest: A.C.S. has recived funding from Gilead Sciences through Emory University. The other authors report no conflicts. 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American Journal of Epidemiology – Oxford University Press
Published: Apr 25, 2018
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