bureau of prisons test inmates upon release. the same american correctional association study also found that most prisons provide hiv-positive individuals with medications while they are in the prison, may provide them with a small supply after they are released, and may also direct them towards community resources where they can receive more medication. treatment of inmates who have tested positive for hiv varies greatly from state to state. for example, in new jersey, female hiv positive prisoners were shackled to their beds for up to six months after being diagnosed. however, ohio and new york, among other states, have infirmaries specifically adapted to attend to the needs of inmates with hiv/aids, and allow some inmates to reside in a hospital for treatment. in addition to this, new york state's division of health services department does regular evaluations of the state prisons' services for aids patients, and also provides space for support groups to meet, and patients to be counseled on their illness. women's symptoms and treatment needs for hiv infection are quite different from those of men, but the treatment resources for incarcerated women are often limited. the treatment of hiv requires a specialist, and generally, prison doctors don't have adequate training to treat women effectively. or, prisons often do not have adequate facilities, staff, or a follow-up treatment system. for example, the 1996 nccd study also found that within the entire california women's prison system, one of the largest in the nation, there was only one full-time specialist able to provide "gender-specific treatment" to women with hiv. male prisoners, however, did have access to gender-specific hiv treatment. abortion federal courts have established, according to constitutional law, that prisoners retain the right to have an abortion once they are incarcerated. however, state standards regarding abortion for incarcerated women are unclear - actions are often left up to the discretion of prison officials on a case-by-case basis. most state abortion policies are written and approved without going through the administrative process which other policies are generally subject to; thus, they are frequently incomplete. in fact, fourteen state docs have no official written abortion policies, and others simply will not release or publish their policies. alaska has a provision which bans abortion funding in its policy on general medical services, but no specific policy guidelines on abortion. other states may not define the exact type of abortions they pay for. most states require that women pay for all of the costs of an abortion procedure, including transportation to the clinic (which is often far due to prisons' rural locations, and the urban locations of most abortion clinics), security, and the actual surgery. minnesota and wisconsin are the only two states which explicitly mention in their policies that they pay for abortions if a woman has been raped. the policy of the federal bureau of prisons since 1987 has been to pay for abortion only in the cases of rape or life endangerment (although they do pay for transportation to the clinic). women's experiences and perceptions of their own access to abortion reflect these policies. in a nationwide survey of correctional health care and inmates' access to abortion, 68% of respondents said that women within their prison were allowed to have an abortion if they requested one. however, many respondents also stated that although their prison did allow access to abortion, women receive little to no help with arranging an appointment, paying for the procedure, and getting themselves to the clinic. contraception incarcerated women are given access to contraceptives, however, most contraceptives offered are irreversible procedures with a lack of counseling in guiding their decision. according to a 2021 research study, approximately 50% of prisons and 83% of jails allow for residing incarcerated women to receive permanent contraception regardless of whether a written policy was enforced. ten out of 22 state prisons and all six jails studied offered reversible contraceptives, however, 6 prisons offered permanent contraception and not reversible contraception. it is estimated that approximately 6-10% of women become incarcerated while pregnant and that most of these women realize this once they have already been taken to either jail or prison. researchers find this to be concerning which leads them to emphasize that institutions should offer emergency contraception for newly incarcerated women. incarcerated women who are newly arrested can be offered emergency contraception based on eligibility. reasons for ineligibility include being over 44 years old, inability to speak english, or they cannot consent. women are also able to decline to enroll for eligibility while some could not be deemed eligible due to the nature of their charges or a research assistant not assisting them within a day of the arrest. nine out of 22 prisons and one of 6 jails covered the costs for giving women permanent contraception while 2 prisons had other methods of payment. some institutions consider the cost to be covered in the fee that is used to cover prison health care. four jails offered residing female prisoners to cover costs using their insurance, government provided insurance, or by payment of hospital bill to receive permanent contraception. female hygiene products inadequate access to female menstrual products inhibits the health of incarcerated females. in 2016, new york passed the first law requiring correctional facilities to provide free feminine hygiene products, and in 2018, the first step act, required federal correctional facilities to provide free feminine hygiene products to prisoners. in federal prisons, feminine hygiene products can be purchased at a commissary or a canteen at inflated prices. some states have enacted legislation requiring or ensuring adequate access to menstrual products in state prisons. as of 2020, 13 states (al, ca, co, ct, fl, ky, la, md, ny, tn, tx, va) and washington, d.c. have enacted legislation requiring free access to such products. however, reports from different states indicate that free feminine hygiene products are less absorbent than industry standard products that can only be purchased in the canteen. in a survey conducted at the missouri department of corrections it was found that even though free sanitary napkins were provided, 80.3 per cent of respondents to the survey reported that they had created tampons themselves because of poor absorption and had reported problems related to increased reproductive and urinary tract infections. cancer and general gynecological care according to the u.s. department of justice bureau of justice statistics, cancer is one of the leading causes of death for women (both inside and outside prison), and one-quarter of deaths of incarcerated women due to cancer are from breast, cervical, ovarian, and uterine cancer. in particular, women in prison are at a high risk for contracting cervical cancer due to their high rates of substance abuse and diseases such as hepatitis c, hiv, and other stis. however, reproductive health care reform in prisons generally focuses on pregnancy or hiv. incarcerated women have higher rates of stis and gynecologic infections than non-incarcerated women. in fact, one study estimated that about 9% of incarcerated women tested positive for gonococcus infection, and between 11 and 17% of incarcerated women are infected with chlamydia. however, not every infected woman will be diagnosed and given treatment, because many prisons only test women who request to be tested, or show symptoms. states often have their own legislation regarding correctional health care, but it doesn't always completely take into consideration the complexities of women's reproductive health. for example, the new york state department of corrections and community supervision (doccs) has issued two main documents which outline their institutional health care policies: the health services policy manual, and the women's health primary care practice guideline (first published in 2000, and updated in 2008 and 2011). within these documents, the patient bill of rights includes the right of a patient to respectful care, the right to refuse treatment, and the right to complete information regarding a diagnosis; the professional code of ethics outlines the standards that staff must follow, including having a respect for human dignity, and a professional relationship with the patient. the doccs does not monitor how well facilities actually adhere to these standards, and there are no consequences for those who do not. also, many women are not informed of their patient's rights, so are unaware when standards have been breached. the doccs has no written policies on pregnancy tests, pregnancy options counseling, abortion, ectopic pregnancy, miscarriage, stillbirth, nutrition for pregnant and nursing women, or hysterectomies, and has incomplete policies regarding menopause, vitamins, health care for pregnant women, women in labor, or women who have recently given birth. the doccs policies stray from community standards in the areas of the starting age for yearly gyn check-ups, the frequency of breast exams and pap smears, follow-up for abnormal pap smears, frequency of prenatal visits and ultrasounds, and the time frame for postpartum check-ups for women who have a caesarean section. the federal bureau of prisons' policy is to provide each inmate with a complete medical exam (which includes gynecological and obstetrical history) within 30 days of admission. the bop currently adheres to the standards for yearly exams put forth by the american college of obstetrics and gynecology. according to a 1997 survey, approximately 90 percent of the inmates in women's state prisons reported having received a gynecologic exam from their institution upon intake. additionally, an american correctional association study found that most women's correctional institutions provided ob/gyn services, prenatal and postpartum care, mammography, and pap smears upon request. fewer provided counseling for inmates regarding their reproductive health, many correctional facilities do not provide follow-up exams, and screenings often do not continue on the recommended schedule. in a new york city juvenile detention facility, the 5,000 youth who went through the system annually were all served by a single physician. less than one-third of the inmates received a pap smear test, and one in five were tested for gonorrhea, chlamydia, and syphilis. women often report long delays and wait times in signing up for appointments with a gyn doctor, and in getting treated. for example, more than half of respondents in a survey of incarcerated women in new york state prisons said that they were not able to see the gyn when necessary, and 47% of respondents stated that their problems became worse in the time that they had to wait. in one extreme case, sara, a woman incarcerated in new york, had to wait seven months before she was finally diagnosed with an aggressive cancer. another woman had to wait four months to receive a colposcopy, a follow-up to her pap test. another woman at the same prison wrote: i’ve never seen the gyn. i dropped a tab explaining to them about being diagnosed with abnormal cells. . . and how i’d like to get a check-up, but no one answered. this was six months ago. in a qualitative study on the experiences of incarcerated women with the papanicolaou test (a test which screens for cervical cancer) in california state prisons, researchers found a lack of communication between medical providers within the prison, which tended to result in long delays or cancellations of treatment, no standardized process for scheduling a pap test, and a lack of education and explanation regarding both the test itself, and how to fill out the medical forms associated with it. in addition to this, women who aren't called in for a pap test are sometimes required to pay a $5 fee if they request one. this can be a significant barrier to requesting a test, considering an average prisoner's wage is around 7 to 13 cents per hour. in the same study, women brought attention to the discomfort suffered by inmates with personal histories of sexual abuse and victimization when they were forced to be examined by a male physician. women interviewed in new york state prisons had similar complaints about their physicians' seeming lack of awareness of female prisoners' past traumas, and the lack of explanation of the procedures. one woman stated: ninety-nine percent of the women have been abused or raped. to have a man take us into an office the size of a closet... stripped down... rough and hurts us... it takes us right back to the beginning." perceptions of medical care another consideration in correctional reproductive health care is the relationship between the prisoner-patients and the physicians. studies have shown