Towards a health-informed approach to penal reform? Evidence from ten countries When we gave birth, the diet for us and the babies was bad, there was no special diet for us or the kids, and this had a bad effect on our health. Female ex-prisoner 4, Kenya Even fewer prisons are equipped to meet the specific needs of women who are pregnant or or have their babies in prison with them (Macmadu et al, 2017). Imprisoned women who are pregnant are a high-risk obstetric group and are more likely to have a medical problem that could affect the pregnancy outcome, yet are less likely to receive adequate antenatal care (Knight et al, 2005). Lesbian, gay, bisexual and transgender (LGBT) prisoners LGBT people face heightened risks of violence, discrimination and abuse, with severe consequences for both physical and mental health. Sexually transmitted infections are a further health concern since LGBT prisoners are at higher risk of rape and assault in some countries (including when prison staff wrongly assume that sexual conduct is consensual (Tarzwell, 2006)). Transgender women are at high risk of violence in custody and experience greater health disparity (McCauley & Brinkley-Rubinstein, 2017). Custody for transgender people is associated with reduced access to healthcare and persistent mental and physical health problems – often reflecting the social marginalisation they experienced prior to imprisonment. Transgender prisoners have specific health needs relating to ensuring (continued) access to hormone therapy and other interventions required for transitioning. Access to suitably qualified healthcare practitioners with an understanding of these needs is important but often lacking in prison settings. Research on the experience of lesbian, gay and bisexual prisoners has mainly focused on the normalisation of homophobia and suppression of gay male sexuality in hyper-masculine prison cultures (for example Jewkes, 2002). The proscription of sexual relationships in prison and the failure to supply condoms and adopt other harm reduction approaches can heighten the risks of disease transmission through same-sex relationships. Young prisoners Children and young people in custody are likely to have experienced multiple levels of disadvantage and to have deep-rooted and complex needs (Jacobson et al, 2010). The physical health of young people in custody tends to be worse than that of their peers in the general population. They are also more likely than other young people to have mental health problems, intellectual disabilities and substance use disorders. In a custodial setting, the irritable mood that often accompanies depressive disorders in younger people can incite aggressive responses in others, or result in self-harming behaviour. In America, an estimated 50 to 75 per cent of youths in contact with the juvenile justice system meet criteria for a mental health disorder; and up to 80 per cent of incarcerated juveniles may have at least one diagnosable mental health disorder (Grisso, 2008). Older prisoners Prisoners tend to experience age-related health problems at a rate equivalent to people a decade older in the community. Accordingly, 50 year-old prisoners show the same signs of age-related infirmity and cognitive decline as 60 year-olds in the general population (Baidawi et al, 2011). This could result from deprivation, stress and the numerous Old and infirm patients were also health disadvantages associated with imprisonment. Many of the kept in jail hospitals. In Central mental and physical health problems faced by older people are Jail, Hisar II one of the admitted exacerbated by factors typical of prison settings, including smokeprisoners was 114 years old. filled environments, lack of exercise, poor diets, higher levels of Commonwealth Human Rights victimisation, and lack of social interaction and mental stimulation. Initiative, India (idem) Most prisons lack any form of geriatric healthcare service and do not cater for the needs of older prisoners with health problems, rendering them all the more vulnerable in custody (Potter et al, 2007). Older prisoners typically suffer from chronic (often multiple) physical health problems. They are susceptible to illnesses such as heart disease, diabetes, hypertension, cancer, hearing and vision impairment and a range of 12