Multipurpose Prevention Technologies for Sexual and Reproductive Health: Gaining Momentum and Promise

Contraception

Multipurpose prevention technologies were the focus of Advancing Prevention Technologies for Sexual and Reproductive Health, an international symposium held in Berkeley, CA, in March 2009. For 2 days, more than 150 participants from developing and industrialized countries discussed and debated the opportunities and challenges for advancing technologies that address multiple sexual and reproductive health (SRH) needs. The symposium proceedings draw from those presentations and the subsequent discussions.2 This editorial seeks to convey the key points of these discussions and engage health care professionals in the effort to fulfill the potential that these technologies might offer.

This editorial was originally published in the journal Contraception and was co-authored by Bethany Young Holt, Maggie Kilbourne-Brook, Alan Stone, Polly Harrison, and Wayne Shields.

Over the past four decades, the world has made substantial
gains in the effort to prevent unplanned pregnancies and reduce the risk of
sexually transmitted infections (STIs), including HIV, and other reproductive
tract infections (RTIs). Yet, STIs and RTIs still cause a heavy health burden,
especially in developing countries, and there is an equally urgent unmet need
for contraception.1,2,3,4,5,6

To date, prevention
strategies have focused largely on single indications, namely, the prevention
of unplanned pregnancy, prevention of STIs or prevention of RTIs. This approach
does not adequately recognize the intrinsic link between unplanned pregnancy
and STIs: a woman at risk of an unplanned pregnancy is often simultaneously at
risk for an STI, including HIV, or other RTI. Thus, there is a critical need
for multipurpose prevention technologies that will allow people to avoid more
than one adverse health outcome.

Multipurpose prevention
technologies were the focus of Advancing Prevention Technologies for Sexual and
Reproductive Health, an international symposium held in Berkeley, CA, in March
2009. For 2 days, more than 150 participants from developing and industrialized
countries discussed and debated the opportunities and challenges for advancing
technologies that address multiple sexual and reproductive health (SRH) needs.
The symposium proceedings draw from those presentations and the subsequent
discussions.2 This editorial seeks to convey the key points of these
discussions and engage health care professionals in the effort to fulfill the
potential that these technologies might offer.

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A
universal health need

Unplanned pregnancy and STIs
typically affect the most disadvantaged groups — especially young women,
adolescents and the poor — the hardest. But women from all socioeconomic groups
face challenges to their SRH.7,8,9,10,11

Each year:

  • More than 120 million couples have an unmet need for
    contraception.

  • An estimated 80 million women experience an unplanned
    pregnancy (45 million of which end in abortion).

  • More than half a million women die from complications
    associated with pregnancy, childbirth and the postpartum period.

  • Roughly 340 million people acquire new gonorrhea,
    syphilis, chlamydia or trichomonas infections.

 

In addition, untold numbers
of individuals acquire chronic infections with the herpes simplex virus (HSV)
and human papillomavirus (HPV), which is the primary cause of cervical cancer.12

Millions of women are
vulnerable to several of these adverse outcomes, yet many women are only able
to access or afford prevention for a single intervention, such as contraception
or treatment for an STI. At the same time, many providers struggle to ensure
that their clients have access to all prevention methods that meet their
multiple needs.

A
new approach

It is time to address SRH
prevention in a more holistic way and to develop prevention tools that address
multiple health risks; are acceptable, affordable, accessible and easy to use;
and can meet individuals’ varying health needs and reproductive intentions.
Such interventions could have a dramatic effect on the health and well-being of
millions of women and their families.

Multipurpose preventive
technologies for SRH could include vaccines, microbicides and devices [such as
intravaginal rings (IVRs), diaphragms and condoms] that provide protection from
unplanned pregnancy; STIs including HIV; and/or other common RTIs. As the
report from the Berkeley symposium explains, “Providing people with suitable
protection is a continuing challenge, especially in settings where access to
health services is limited, and the availability of technologies that address
more than one indication would be a significant improvement in terms of
efficiency and convenience. The provider would be able to stock, supply, and
advise on a more compact range of products, and the user would need to
purchase, understand, store, and use fewer products. A further advantage is
that users would be protected automatically against more than one indication
even if they had obtained the product with regard to a single perceived risk”.2
While such technologies will benefit both men and women, women will gain the
most, as they are more vulnerable to these risks for both physiological and
societal reasons.

Some multipurpose prevention
technologies already exist, but they are woefully underutilized. Male and
female condoms, for instance, prevent both unplanned pregnancy and STIs. Male
condoms are not always used consistently. While the launch of the UNFPA Global
Female Condom Initiative in 2005 has significantly increased access to female
condoms, this woman-controlled prevention method has nonetheless been slow to
achieve widespread distribution or user acceptance and more must be done to
increase its demand and access.13

Extensive experience with
existing prevention methods — condoms, diaphragms, IVRs, hormonal methods and
vaccines — and recent advances in the development of microbicides and oral
pre-exposure prophylaxis with antiretroviral drugs have laid a solid foundation
for the development of new prevention technologies for multiple SRH risks.
Several of these technologies, such as more user-friendly female condoms and
diaphragms, are in the late stages of clinical testing. The PATH Women’s
Condom, for example, has gone through several clinical studies and is entering
a regulatory study for its approval in China and the US. A new generation of
microbicides, including products based on antiretroviral drugs, continues to
hold promise despite the failure of some of the earlier products to protect,
including the polyanion PRO 2000 (http://www.mdp.mrc.ac.uk).

Momentum is building. The
National Institutes of Health, US Agency for International Development, the
Ministry of Health of China and other donors are currently supporting efforts
to advance multipurpose prevention strategies, including preclinical research,
effectiveness trials and pre- and postintroduction studies on a range of
potential multipurpose prevention products, both coitally dependent and long
acting.2

Collaborations between different organizations and research
disciplines, such as behavioral scientists, immunologists, engineers,
epidemiologists, drug developers, clinicians, and advocates, are evolving and
helping to advance some exciting novel SRH prevention approaches.14, 15,
16, 17

Research efforts include semisolid gels, gel capsules, films,
IVRs, sponges, compound-releasing intrauterine systems, diaphragms, and male
and female condoms with and without spermicidal or anti-infective agents.
Listed here are some of the various entities which are currently pursuing this
work: CONRAD, Family Health International, International Partnership for
Microbicides, Ministry of Health of China, PATH, the Population Council, Queens
University of Belfast, University of Witwatersrand, University of Alabama,
University of California Berkeley, University of California San Francisco,
University of Utah, biotech companies (e.g., ReProtect, Mapp Biopharmaceutical,
Inc., and Osel, Inc.) and others. The CONRAD program, for example, has
dedicated a major portion of its portfolio to combined approaches.2
The Population Council, PATH, International Partnership for Microbicides,
University of Utah and CONRAD are working on multipurpose IVRs and diaphragms
which would be impregnated with contraceptives and anti-STI microbicides.2,18

Other technologies in development include probiotics that prevent bacterial and
urinary infections and could be modified to serve as drug-delivery systems.19,20
Multipurpose vaccines are also in development and the discovery of
potentially suitable antigens for several STI pathogens is progressing,
including chlamydia, HIV, HSV, gonorrhea and trichomonas.

For each of the
technologies, the challenge will be to ensure that their production and
deployment can be sufficiently cost-effective for widespread use in developing
countries with minimal health care infrastructure. The Berkeley symposium gave
voice to many promising ideas and a shared belief that multipurpose
technologies can and should be developed. It is, of course, recognized that
these technologies will not by themselves achieve all the desired goals and
that they will need to be introduced with care, and their deployment preceded
and accompanied by well-designed educational programs.

The effort to develop
multipurpose prevention technologies and bring them to populations in need will
encounter many complex challenges. The work will require technical innovation,
scientific persistence, significant human and technical resources, and,
crucially, political will. Given the rapid evolution of relevant technologies
and an increasingly focused effort, these challenges can be overcome. With
sufficient funding, new tools such as these could become the building blocks
for cost-effective prevention efforts. When combined with more effective
programming of existing prevention technologies, women and communities will
benefit from improved health.

Recommended
actions

Multifaceted collaboration
will be required to bring multipurpose prevention technologies within reach.
Researchers, funders, product developers, engineers, microbiologists,
behavioral scientists, advocates and others must work together to maximize
their technical expertise, community involvement and political will. In
addition, these stakeholders must promote cross-disciplinary communication and
collaboration, ensuring that parallel development tracks interact at strategic
points.

Health professionals can
contribute their expertise and voice toward this effort in multiple ways. For
example, they can:

  • Educate clients about the intrinsic link between STIs
    and unplanned pregnancies and the need for simultaneous prevention.

  • Clinicians can educate
    their clients about the need to prevent STIs and unplanned pregnancy and
    encourage clients to use existing combined methods to increase their
    levels of protection, such as male or female condoms for STI/HIV
    prevention combined with hormonal methods and IUDs, since these are the
    most effective contraceptive options now available.

  • Seek opportunities to facilitate cross-disciplinary
    collaboration.
  • Researchers can explore
    opportunities to collaborate with researchers in different fields that
    can complement their work. They can also participate in conferences and
    learn about relevant work outside their particular research area. 
  • Clinicians can find
    ways to help researchers recruit participants into clinical trials of new
    prevention products and participate in product acceptability research.
    Data on these topics are needed in diverse geographic regions in the US
    and internationally as well as in communities with diverse social and
    demographic characteristics.
  • Advocate for increased support for multipurpose
    prevention technologies.
     

  • All health care
    professionals can educate donors and funders about the need for intensive,
    multidisciplinary research aimed at providing affordable and acceptable
    multipurpose prevention technologies.

  • Professionals can also
    educate legislators and policymakers about the importance of multipurpose
    prevention technologies.
     

  • They can inform other
    stakeholders — professional societies, organizations and coalitions;
    reproductive health and HIV organizations; and health advocacy groups —
    about the need for greater investment in multipurpose prevention
    technologies for SRH
  • All supporters can
    spread the word within their professional networks by presenting on this
    topic and submitting articles to these networks’ newsletters and related
    communication outlets.

Conclusion

This is a pivotal time for
reproductive health professionals. We have the opportunity to identify and
prioritize opportunities to achieve a significant health impact in
industrialized as well as in developing countries by accelerating the
development of multipurpose prevention technologies. Together, we can address
this need and improve the health and well-being of women and their families
around the world.

References

  1. Guttmacher Institute and United Nations Population Fund
    (UNFPA). Adding It Up: The Benefits of Investing in Sexual and Reproductive
    Health Care. New York: AGI. Available at: http://www.guttmacher.org/pubs/addingitup.pdf.
    2003.
  2. Stone A. Symposium Report: Advancing Prevention
    Technologies for Sexual and Reproductive Health. Available at: http://www.cami-health.com/APT2009/PDFs/report-aug09.pdf.
    2009.
  3. Cates W, Steiner MJ. Dual protection against unplanned
    pregnancy and sexually transmitted infections: what is the best
    contraceptive approach?. Sex Transm Dis. 2002;29:168–174.
  4. International Planned Parenthood Federation, University
    of California San Francisco, Joint United Nations Program on HIV/AIDS,
    UNFPA, World Health Organization. Sexual & reproductive health and
    HIV. Linkages: evidence review and recommendations. Available online at: http://data.unaids.org/pub/Agenda/2009/2009_linkages_evidence_review_en.pdf.
    2009.
  5. Wilcher R, Petruney T, Reynolds HW, Cates W. From
    effectiveness to impact: contraception as an HIV prevention intervention. Sex
    Transm Infect
    . 2008;84(Suppl 2):ii54–ii60.
  6. Feldblum PJ, Nasution MD, Hoke TH, et al. Pregnancy
    among sex workers participating in a condom intervention trial highlights
    the need for dural protection. Contraception. 2007;76:105–110.
  7. Allsworth JE, Lewis VA, Peipert JF. Viral sexually
    transmitted infections and bacterial vaginosis: 2001–2004 National Health
    and Nutrition Examination Survey data. Sex Transm Dis.
    2008;35:791–796.
  8. Frost JJ, Singh S, Finer LB. US women’s one-year
    contraceptive use patterns, 2004. Perspect Sex Reprod Health.
    2007;39:48–55.
  9. Glasier A, Gulmezoglu AM, Schmid GP, Moreno CG, Van
    Look PFA. Sexual and reproductive health: a matter of life and death. Lancet.
    2006;368:1550–1551.
  10. CDC. HIV/AIDS Surveillance Report 2003; (Vol. 15).
    Atlanta: US Department of Health and Human Services, CDC; 2005.
  11. The World Bank and International Monetary Fund. Global
    Monitoring Report 2009: A Development Emergency. 2009; Washington DC.
  12. Bosch FX, de Sanjosé S. The epidemiology of human
    papillomavirus infection and cervical cancer. Dis Markers.
    2007;23:213–227.
  13. UNFPA. Empowering women to protect themselves:
    promoting the female condom in Zimbabwe. Available at: http://www.unfpa.org/public/cache/offonce/News/pid/3913;jsessionid=4FBD9DA8AD4EFB9F069224AC0EEB0670.
    2009.
  14. Verguet S, Young Holt B, Szeri A. Reframing behavioral
    acceptability of microbicide gel vehicles in conjunction with biophysical
    constraints. Presented at the 2009 Advancing Prevention Technologies for
    Sexual and Reproductive Health Symposium, Berkeley California. Available
    at: http://www.cami-health.com/APT2009/posters.html2009.
  15. Morrow K, Fava J, Rosen R, Kiser P, Katz D. Linking
    biophysical functions to user perceptions and acceptability in preclinical
    product development. Presented at the 2009 Advancing Prevention
    Technologies for Sexual and Reproductive Health Symposium, Berkeley
    California. Available at: http://www.cami-health.com/APT2009/posters.html.
  16. Arntzen C, Herbst-Kralovetz M, Mason H, Tacket C,
    Khanna N, Zeitlin L, Whaley K The vaccine and microbicide alliance.
    Presented at the 2009 Advancing Prevention Technologies for Sexual and
    Reproductive Health Symposium, Berkeley California. Available at: http://www.cami-health.com/APT2009/posters.html.
  17. Alliance for Microbicide Development. HIV/STI
    Prevention Research and Development: October 2009 Pipeline Update of
    Microbicide and PrEP Candidates. Silver Spring, MD. Available at: http://www.microbicide.org/uploads/3/1/2/1/3121935/microbicide_pipeline_update_1_oct_2009.pdf.
  18. Nath A, Sitruk-Ware R. Novel non-oral hormonal
    contraceptive methods for women. Exp Rev Obstet Gynecol.
    2009;4:565–573.
  19. Bolton M, van der Straten A, Cohen CR. Probiotics:
    potential to prevent HIV and sexually transmitted infections in women. Sex
    Transm Dis
    . 2008;35:214–225.
  20. Liu X, Lagenaur LA, Simpson DA, et al. Engineered
    vaginal lactobacillus strain for mucosal delivery of the human
    immunodeficiency virus inhibitor cyanovirin-N. Antimicrob Agents
    Chemother
    . 2006;50:3250–3259.

Commentary Abortion

It’s Time for an Abortion Renaissance

Charlotte Taft

We’ve been under attack and hanging by a thread for so long, it’s been almost impossible to create and carry out our highest vision of abortion care.

My life’s work has been to transform the conversation about abortion, so I am overcome with joy at the Supreme Court ruling in Whole Woman’s Health v. Hellerstedt. Abortion providers have been living under a very dark cloud since the 2010 elections, and this ruling represents a new day.

Abortion providers can finally begin to turn our attention from the idiocy and frustration of dealing with legislation whose only intention is to prevent all legal abortion. We can apply our energy and creativity fully to the work we love and the people we serve.

My work has been with independent providers who have always proudly delivered most of the abortion care in our country. It is thrilling that the Court recognized their unique contribution. In his opinion, after taking note of the $26 million facility that Planned Parenthood built in Houston, Justice Stephen Breyer wrote:

More fundamentally, in the face of no threat to women’s health, Texas seeks to force women to travel long distances to get abortions in crammed-to-capacity superfacilities. Patients seeking these services are less likely to get the kind of individualized attention, serious conversation, and emotional support that doctors at less taxed facilities may have offered.

This is a critical time to build on the burgeoning recognition that independent clinics are essential and, at their best, create a sanctuary for women. And it’s also a critical time for independent providers as a field to share, learn from, and adopt each other’s best practices while inventing bold new strategies to meet these new times. New generations expect and demand a more open and just society. Access to all kinds of health care for all people, including excellent, affordable, and state-of-the-art abortion care is an essential part of this.

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We’ve been under attack and hanging by a thread for so long—with our financial, emotional, and psychic energies drained by relentless, unconstitutional anti-abortion legislation—it’s been almost impossible to create and carry out our highest vision of abortion care.

Now that the Supreme Court has made it clear that abortion regulations must be supported by medical proof that they improve health, and that even with proof, the burdens can’t outweigh the benefits, it is time to say goodbye to the many politically motivated regulations that have been passed. These include waiting periods, medically inaccurate state-mandated counseling, bans on telemedicine, and mandated ultrasounds, along with the admitting privileges and ambulatory surgical center requirements declared unconstitutional by the Court.

Clearly 20-week bans don’t pass the undue burden test, imposed by the Court under Planned Parenthood v. Casey, because they take place before viability and abortion at 20 weeks is safer than childbirth. The federal Hyde Amendment, a restriction on Medicaid coverage of abortion, obviously represents an undue burden because it places additional risk on poor women who can’t access care as early as women with resources. Whatever the benefit was to late Rep. Henry Hyde (R-IL) it can’t possibly outweigh that burden.

Some of these have already been rejected by the Court and, in Alabama’s case, an attorney general, in the wake of the Whole Woman’s Health ruling. Others will require the kind of bold action already planned by the Center for Reproductive Rights and other organizations. The Renaissance involves raising an even more powerful voice against these regulations, and being firm in our unwillingness to spend taxpayer dollars harming women.

I’d like to entertain the idea that we simply ignore regulations like these that impose burdens and do not improve health and safety. Of course I know that this wouldn’t be possible in many places because abortion providers don’t have much political leverage. This may just be the part of me that wants reproductive rights to warrant the many risks of civil disobedience. In my mind is the man who stood in front of moving tanks in Tiananmen Square. I am yearning for all the ways to stand in front of those tanks, both legal and extralegal.

Early abortion is a community public health service, and a Renaissance goal could be to have early abortion care accessible within one hour of every woman in the country. There are more than 3,000 fake clinics in this country, many of them supported by tax dollars. Surely we can find a way to make actual services as widely available to people who need them. Of course many areas couldn’t support a clinic, but we can find ways to create satellite or even mobile clinics using telemedicine to serve women in rural areas. We can use technology to check in with patients during medication abortions, and we can provide ways to simplify after-care and empower women to be partners with us in their care. Later abortion would be available in larger cities, just as more complex medical procedures are.

In this brave new world, we can invent new ways to involve the families and partners of our patients in abortion care when it is appropriate. This is likely to improve health outcomes and also general satisfaction. And it can increase the number of people who are grateful for and support independent abortion care providers and who are able to talk openly about abortion.

We can tailor our services to learn which women may benefit from additional time or counseling and give them what they need. And we can provide abortion services for women who own their choices. When a woman tells us that she doesn’t believe in abortion, or that it is “murder” but she has to have one, we can see that as a need for deeper counseling. If the conflict is not resolved, we may decide that it doesn’t benefit the patient, the clinic, or our society to perform an abortion on a woman who is asking the clinic to do something she doesn’t believe in.

I am aware that this last idea may be controversial. But I have spent 40 years counseling with representatives of the very small, but real, percentage of women who are in emotional turmoil after their abortions. My experience with these women and reading online “testimonies” from women who say they regret their abortions and see themselves as victimized, including the ones cited by Justice Kennedy in the Casey decision, have reinforced my belief that when a woman doesn’t own her abortion decision she will suffer and find someone to blame for it.

We can transform the conversation about abortion. As an abortion counselor I know that love is at the base of women’s choices—love for the children they already have; love for their partners; love for the potential child; and even sometimes love for themselves. It is this that the anti-abortion movement will never understand because they believe women are essentially irresponsible whores. These are the accusations protesters scream at women day after day outside abortion clinics.

Of course there are obstacles to our brave new world.

The most obvious obstacles are political. As long as more than 20 states are run by Republican supermajorities, legislatures will continue to find new ways to undermine access to abortion. The Republican Party has become an arm of the militant anti-choice movement. As with any fundamentalist sect, they constantly attack women’s rights and dignity starting with the most intimate aspects of their lives. A society’s view of abortion is closely linked to and mirrors its regard for women, so it is time to boldly assert the full humanity of women.

Anti-choice LifeNews.com contends that there have been approximately 58,586,256 abortions in this country since 1973. That means that 58,586,256 men have been personally involved in abortion, and the friends and family members of at least 58,586,256 people having abortions have been too. So more than 180 million Americans have had a personal experience with abortion. There is no way a small cadre of bitter men with gory signs could stand up to all of them. So they have, very successfully so far, imposed and reinforced shame and stigma to keep many of that 180 million silent. Yet in the time leading up to the Whole Woman’s Health case we have seen a new opening of conversation—with thousands of women telling their personal stories—and the recognition that safe abortion is an essential and normal part of health care. If we can build on that and continue to talk openly and honestly about the most uncomfortable aspects of pregnancy and abortion, we can heal the shame and stigma that have been the most successful weapons of anti-abortion zealots.

A second obstacle is money. There are many extraordinary organizations dedicated to raising funds to assist poor women who have been betrayed by the Hyde Amendment. They can never raise enough to make up for the abandonment of the government, and that has to be fixed. However most people don’t realize that many clinics are themselves in financial distress. Most abortion providers have kept their fees ridiculously and perilously low in order to be within reach of their patients.

Consider this: In 1975 when I had my first job as an abortion counselor, an abortion within the first 12 weeks cost $150. Today an average price for the same abortion is around $550. That is an increase of less than $10 a year! Even in the 15 states that provide funding for abortion, the reimbursement to clinics is so low that providers could go out of business serving those in most need of care.

Over the years a higher percent of the women seeking abortion care are poor women, women of color, and immigrant and undocumented women largely due to the gap in sexual health education and resources. That means that a clinic can’t subsidize care through larger fees for those with more resources. While Hyde must be repealed, perhaps it is also time to invent some new approaches to funding abortion so that the fees can be sustainable.

Women are often very much on their own to find the funds needed for an abortion, and as the time goes by both the costs and the risk to them increases. Since patients bear 100 percent of the medical risk and physical experience of pregnancy, and the lioness’ share of the emotional experience, it makes sense to me that the partner involved be responsible for 100 percent of the cost of an abortion. And why not codify this into law, just as paternal responsibilities have been? Perhaps such laws, coupled with new technology to make DNA testing as quick and inexpensive as pregnancy testing, would shift the balance of responsibility so that men would be responsible for paying abortion fees, and exercise care as to when and where they release their sperm!

In spite of the millions of women who have chosen abortion through the ages, many women still feel alone. I wonder if it could make a difference if women having abortions, including those who received assistance from abortion funds, were asked to “pay it forward”—to give something in the future if they can, to help another woman? What if they also wrote a letter—not a bread-and-butter “thank you” note—but a letter of love and support to a woman connected to them by the web of this individual, intimate, yet universal experience? This certainly wouldn’t solve the economic crisis, but it could help transform some women’s experience of isolation and shame.

One in three women will have an abortion, yet many are still afraid to talk about it. Now that there is safe medication for abortion, more and more women will be accessing abortion through the internet in some DIY fashion. What if we could teach everyone how to be excellent abortion counselors—give them accurate information; teach them to listen with nonjudgmental compassion, and to help women look deeper into their own feelings and beliefs so that they can come to a sense of confidence and resolution about their decision before they have an abortion?

There are so many brilliant, caring, and amazing people who provide abortion care—and room for many more to establish new clinics where they are needed. When we turn our sights to what can be, there is no limit to what we can create.

Being frustrated and helpless is exhausting and can burn us out. So here’s a glass of champagne to being able to dream again, and to dreaming big. From my own past clinic work:

At this clinic we do sacred work
That honors women
And the circle of life and death.

Analysis Human Rights

Erika Rocha’s Suicide Brings Attention to the Dire Need for Mental Health Care in Prison

Victoria Law

Erika Rocha's was the first suicide of the year at Corona's California Institution for Women (CIW), which is currently at 130 percent capacity. CIW's suicide rate, however, is more than eight times the national rate for women behind bars.

On April 14, 2016, one day before her parole hearing, Erika Rocha committed suicide. The 35-year-old had spent 21 years behind bars. But what should have been a day of hope for Rocha, her family, and her friends instead became a day of mourning.

Rocha’s was the first suicide of the year to rock Corona’s California Institution for Women (CIW), which is currently at 130 percent capacity. CIW’s suicide rate, however, is more than eight times the national rate for women behind bars. The prison had four suicides and 16 attempts in 2014. In 2015, it had two suicides and 35 attempts. And in the first two months of 2016, CIW had four additional suicide attempts.

These numbers, advocates say, display the consequences of the lack of mental health resources for women in prison, some of whom have been behind bars for decades.

The need for comprehensive mental health care has long plagued California prisons. In 1990, advocates filed Coleman vs. Wilson, a class-action civil rights lawsuit alleging unconstitutional medical care by the California Department of Corrections and Rehabilitation (CDCR). In 1995, a U.S. District Court ruled in Coleman that mental health-care access in the state prisons violated the Eighth Amendment prohibition against cruel and unusual punishment; the following year, it appointed a special master to review California’s prisons and to monitor mental health care. That special master is still monitoring CDCR’s mental health care.

In 2013, Lindsay Hayes, a suicide prevention expert, audited all of the state’s prisons for their suicide prevention plans. In 2015, he re-audited 18 of those prisons. In the report he released in January 2016, he noted that, while some prisons had made progress on the issue, “CIW continued to be a problematic institution that exhibited numerous poor practices in the area of suicide prevention.” These poor practices, Hayes wrote, included low completion of suicide risk evaluations, inadequate treatment planning, low compliance rates for annual suicide prevention training, and multiple suicides during the calendar year.

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“This Seemed To Be the Only Way”

No one will ever know what pushed Rocha over the edge. But others at CIW say that those who need mental health treatment there, both before and after their suicides, face a lack of preventive treatment, including counseling, and almost no follow-up.

Amber, who asked to be referred to by a pseudonym, noted that the prison lacks available mental health programming. She had already spent 14 years at another prison when she was transferred to CIW. There, she found that nearly every self-help and support group had a long waiting list.

In addition, mental health treatment was sparse. “I would only see mental health [staff] every 90 days, and that was only about five minutes,” she recalled in an interview with Rewire. “As time went on and I became more and more frustrated by the lack of anything to take my mind off my emptiness, I got more lonely and hopeless.” She stopped talking to her friends, stopped eating, lost interest in her appearance, and began losing weight. No one noticed these red flags. She told mental health staff that she wanted to stop taking medication. No one, she said, questioned her decision.

In July 2014, Amber and her friend Mindy (also a pseudonym) decided to end their lives together. Once they made their decision, Amber remembered feeling a sense of relief: “I was happy. I knew my misery and pain were ending. … This seemed to be the only way.” The two slit their throats, losing consciousness. But someone found them, alerted staff and they were transported to the hospital. How they were treated next, they said, didn’t make them feel any more hopeful about life.

After being released from the hospital, both women were placed in a mental health crisis bed, commonly referred to as “suicide watch” among people in prison. Amber described suicide watch as a place “where they strip you naked and put a hard gown on you, basically a life jacket. They give you a blanket made of the same material and have a bright light on with a nurse watching and recording [on paper] your every move. … You are not allowed anything for the first week. Then you can ‘earn’ a book. And maybe a muumuu gown if you are calm and cooperative. You aren’t even allowed a roll of toilet paper. When you need to use the toilet [in your cell], they hand you a tiny bit and watch you use it.”

Mindy spent 11 days in suicide watch; Amber was there for two weeks. Both were then placed in the prison’s specialty care unit, where they were able to have human interactions and access to group programming, which Amber described as 14 hours a week of coloring, watching movies, singing karaoke, and walking.

However, suicide watch is frequently full. In those cases, people are placed in an “overflow unit” in the prison’s Security Housing Unit (SHU), an isolation unit where people are locked in their cells for 23 to 24 hours each day. This kind of isolation can cause myriad mental health issues, including anxiety, panic, depression, agoraphobia, paranoia, aggression, and even neurological damage.

Krista Stone-Manista is an attorney with San Francisco-based Rosen Bien Galvan & Grunfeld, which co-litigated the Coleman case. She is also part of the team now monitoring compliance. She notes that, when a person reports feeling suicidal, she is supposed to be moved to a mental health crisis bed. But, because there aren’t enough mental health crisis beds, California prisons utilize what’s known as “alternative housing,” which might include isolation until a bed opens up. “What we’re seeing is that people are repudiating their suicidal ideation to get out of alternative housing,” she told Rewire. That means that they don’t receive counseling or any other type of mental health treatment.

But even when they are placed on suicide watch, the special master, in his 2015 review of CIW, found that “patients were discharged from the mental health crisis bed as soon as they reported they were no longer suicidal, with little effort to determine the underlying causes of their initial reports of suicidality.”

People incarcerated at CIW report that its environment has not improved in the two years since Amber and Mindy attempted to take their lives. In March 2015, Stephanie Feliz hung herself. Mindy, who was in the mental health unit at the time, said that Feliz walked in and requested services for a mental health crisis. Despite having a history of suicide attempts and self-mutilation, Mindy said staff told her that she had already been seen the day before. According to Mindy, Felix returned to her cell, where she was found dead two hours later. This treatment is not unusual, Mindy noted, writing to Rewire in a letter that she too has requested mental health services only to encounter delays and, at times, outright dismissal.

But no matter what changes the institution makes, Stone-Manista pointed out, “There’s only so much CIW can do for someone who is chronically suicidal. They’re not a hospital.”

CDCR did not respond to queries about the numbers of suicides and suicide attempts at CIW or about its suicide prevention practices.

Rocha’s Years in Prison

When Rocha was 14 years old, she and several older teens were arrested for an accidental shooting. Rocha was charged as an adult and, without a parent or guardian present, questioned by police and, according to advocates, pressured to plead guilty by the prosecutor. She did and was sentenced to 19 years to life. Rocha was initially sent to a juvenile prison, where she spent two years. At age 16, she was transferred to the adult Valley State Prison in Chowchilla. There, prison officials placed her in solitary, ostensibly for her own protection due to her age. She stayed in isolation for one year.

Windy Click is now program coordinator for the advocacy group California Coalition for Women Prisoners (CCWP). She was imprisoned at Valley State when Rocha arrived and met the girl shortly after she had turned 19. Rocha was looking for something positive to do and asked how to get to the prison library. While Click, then in her 30s, and Rocha never became close friends, each time Rocha was released from solitary, she sought the older woman out.

“She was a funny girl,” Click recalled in an interview with Rewire. “She liked to joke and be light-hearted.” One of the topics that Rocha frequently joked about was growing old in prison. “She’d say she would be an old lady in prison.”

Other times, however, the girl had a hard time coping with prison. “She would be very shaky, trembling almost,” Click recalled. “‘I can’t do this no more,’ she’d tell me.” During those times, Click said, Rocha would tell prison staff that she was afraid for her life and request to be placed in administrative segregation, a form of isolation commonly known as ad-seg, where she would be locked in a cell for 23 to 24 hours each day. Prison staff obliged and Rocha would be placed in isolation. When she returned to general population, Click remembered that the girl would seem better but “after a day or so, she’d be back to that shakiness.”

Click recalled one conversation in which she told Rocha, “This place isn’t the last place you’ll ever be.” But, she remembered, the younger woman couldn’t see the light at the end of the tunnel.

It didn’t help that Rocha spent more than a decade without seeing her family, who lived nearly 300 miles in the Los Angeles area. Lacking a car, they could not make the trek to Central Valley. It was not until Rocha was moved to CIW, 15 minutes from their home, that they could visit. By then, Rocha’s father had died; her stepmother Linda Reza brought her three daughters as soon as Rocha was allowed to receive visits.

“She was still the same little kid that left us,” Reza remembered of that first visit in an interview with Rewire.

That was how Geraldine, Rocha’s half-sister, saw it as well: “She’s nine years older than me. But it was like I was the big sister.”

Rocha got along best with her teenage sister Freida, who was born after her incarceration and whom she met for the first time in the CIW visiting room. When the family visited, Reza remembered that Rocha and Freida would head to the visiting room’s play area and play on the swings. Reza recalled that, when Rocha received news of her upcoming hearing, she and Freida made plans to share a room at Reza’s house, clipping magazine pictures and envisioning how to decorate the room.

Colby Lenz, a volunteer legal advocate with CCWP, saw a different, more vulnerable side, one that Rocha did her best to keep from her family. “She was the most fragile and traumatized person I had ever met in prison,” Lenz recalled about their first meeting less than two years ago. It was only partway through the legal visit that Rocha began to open up. “She went back to [age] 14 or 15 and talked about her early years—how much time she had done in solitary, how they treated her.”

Under California’s SB 260, which passed in 2013 and went into effect in January 2014, Rocha became eligible for a youth parole hearing for youth sentenced as adults to long prison sentences. As part of the hearing process, she was given a psychiatric evaluation. But, said Lenz, no one explained to her why she was undergoing a psychiatric evaluation. The process brought her back to the police interrogations she had gone through at age 14 without a parent or guardian present. Frightened and retraumatized, Rocha not only waived her hearing, but also attempted to take her own life.

In 2015, Rocha learned she was scheduled for another youth parole hearing on April 15, 2016. In the weeks before, Reza recalled that Rocha was excited. The last time she called, Reza wasn’t able to answer her phone. The message Rocha left was hopeful. “Tell my sisters I know they’re going to kick my ass when I get home,” she said. “But that’s okay, I’ll take it.”

“In a Hopeless Place, Most Don’t Make It”

Since Rocha’s death, CCWP has reported that at least 22 people in CIW have been placed on suicide watch for attempting suicide or stating that they felt suicidal.

Mariposa, who asked to go by her stage name, is one of those 22 placed on suicide watch. She is the co-author of the one-woman play Mariposa and the Saint about her own time in solitary. She was also Rocha’s cellmate and fiancée. After Rocha was found hanging in their shared cell, Mariposa was immediately placed in suicide watch, where she was not allowed regular visits, phone calls, or mail. She was, however, allowed a legal visit with CCWP, but, advocates told Rewire, kept in a treatment cage the entire time.

Those inside the prison report that the lack of programs and activities contributes to the feeling of hopelessness. “People have way too much time to think and be in their heads,” wrote another woman at CIW to Rewire one month before Rocha’s death. “A lot of us are only hanging on by hope alone. In a hopeless place, most don’t make it.”

Krista Stone-Manista noted that CDCR is working on new policies and procedures to move people who need more care or longer-term care to inpatient care rather than keeping them inside the prisons, which are often inadequately staffed with mental health professionals. She also pointed to CDCR’s reduction of the use of solitary confinement, noting that studies have shown the damage to mental health and that suicides and suicide attempts often occur in segregation. In addition, she says, CDCR is working on how to respond to reports of suicidal thoughts before they become attempts or actual suicides.

All of these efforts are too late for Rocha. “When I get out, I want you to take me to the park,” Reza remembered her stepdaughter telling her and her sisters during one visit. “I want to play on the swings and the slide and run in the grass.”

Reza plans to honor that wish. “After her cremation, we’re going to have a reception in the park,” she said. “We’re going to put her on the swings.”