Access to Health Care and Treatment Among Individuals Convicted of Sexual Offenses Paroled to Urban and Rural Communities

Abstract

Returning from prison to the community is rife with challenges. For individuals with health care, mental health, or substance abuse treatment needs, the reentry period can be especially vulnerable. Furthermore, these services are not evenly distributed across communities. This study explores barriers to health care and treatment among individuals convicted of sexual offenses who are returning from prison to urban and rural communities. Using data from in-depth interviews and geographic data, our analysis highlights the needs of this population that is often mandated to treatment. Access to treatment and health care is a challenge for many participants and is exacerbated in rural areas because of a dearth of providers and the long distance to treatment offices. The results highlight the deficiency of treatment services across the urban–rural continuum and support new innovations in service provisions.

Keywords

reentry treatment sex offenses transportation rural health care

Many Americans face barriers to health care including the approximately 1.5 million currently serving time in prison (Carson, 2019). Incarceration extends and deepens health care disparities (Massoglia, 2008). Individuals who have been incarcerated are more likely to experience health problems than the general public, and the conditions of confinement and process of reentry from prison to the community can negatively affect long-term physical and mental health (Fahmy & Wallace, 2018; Link et al., 2019; Loeb & AbuDagga, 2006; Massoglia & Pridemore, 2015). This population also has very high rates of substance use and many are mandated to treatment in the community, but institutional care is sparse and there are substantial treatment gaps in the community (Bronson et al., 2017; Sung et al., 2011). Individuals returning from prison often lack access to material resources, like transportation, that facilitate connections to medical care and treatment (Bohmert & DeMaris, 2018; Wakefield & Uggen, 2010).

Mental health and substance abuse programming and health care services are not equally distributed across communities, and characteristics of place, like rurality, shape health outcomes (Monnat & Beeler Pickett, 2011; Weinhold & Gurtner, 2014; Wodahl, 2006). There is ample evidence to suggest that individuals living in rural areas have a lower life expectancy and poorer health overall (Kroneman et al., 2010; Singh & Siahpush, 2014), but these studies have not been replicated with populations on parole. Most work on reentry has focused on individuals returning to urban communities, and very little is known about the process of reentry in rural contexts (see Wodahl, 2006), and even less about the treatment needs and health outcomes of rural residents on parole.

Furthermore, most scholarship on access to treatment and health care among formerly incarcerated persons has been conducted using general parole samples, but there is cause to believe that the nature of the conviction, and the associated requirements for compliance on parole, may condition the relationship. Individuals with a sex offense conviction are a unique analytic case as participation in cognitive-behavioral treatment is often a condition of parole (Kras et al., 2018; Savage & Windsor, 2018). Furthermore, persons convicted of a sex offense face considerable stigma and have low social status (Huebner et al., 2019), an important correlate of negative health outcomes (Marmot, 2004). Understanding the barriers to health care and rehabilitative services has the potential to benefit individual and community health and may help people comply with mandated programming, which has been associated with reduced rates of recidivism and long-term success (Kim et al., 2016; Schmucker & Lösel, 2017).

This article considers the structural and spatial differences in access to treatment, broadly conceptualized to include mental health and substance abuse programming and other rehabilitative services that are often mandated by court and correctional agencies, and health care among individuals convicted of a sexual offense and extends research in several ways. We document the prevalence and nature of health and treatment needs among a sample of individuals paroled for a sexual offense and consider how these experiences vary for urban and rural residents. By analyzing interviews and geographic data from a sample of 62 men and women released on parole for a sexual offense, this work highlights several barriers to effective service provision that could be addressed through responsive and boundary spanning correctional policy.

Literature Review

Treatment, Health Care, and Access Barriers

Although incarcerated persons are traditionally omitted from larger population health studies, researchers have documented the substantial need for mental and physical health care services and substance abuse treatment among this population (Fahmy & Wallace, 2018). For example, incarceration increases the likelihood of major depressive symptoms while imprisoned and after release, with rates approximately 2 times higher than nonincarcerated populations (Massoglia, 2008; Turney et al., 2012). Researchers found that 50% of incarcerated individuals report a chronic health condition (Maruschak & Berzofsky, 2015), and upward of 38% meet the criteria for a diagnosis of a serious mental health disorder (Bronson & Berzofsky, 2017). Substance abuse is markedly higher among incarcerated persons. In a recent analysis of a nationwide incarcerated sample, 58% of individuals met the criteria for drug dependence or abuse, compared with approximately 5% of the general population (Bronson et al., 2017). There is evidence that the effect of imprisonment on health will only increase in the coming years as individuals are serving longer sentences and multiple terms of incarceration—two factors that have shown to increase the health care needs of individuals when they return to the community (Carson & Sabol, 2016; Porter & DeMarco, 2019).

Individuals returning home from prison also face a multitude of barriers in obtaining and consistently participating in rehabilitative programming and mental health and drug treatment, even though it is often ordered as a condition of parole. For example, formerly incarcerated persons are 3 times more likely to report unmet substance abuse treatment needs when compared with the general population (24% vs. 8.5%), and lack of financial resources is the most cited barrier to treatment among this population (Sung et al., 2011). In addition, approximately 17% of formerly incarcerated persons reported that they did not receive services because of lack of access to transportation or distance to treatment, a theme echoed in other studies of this type (Bohmert & DeMaris, 2018; Sachs & Miller, 2018; Spaulding et al., 2011). Health care needs are more pronounced for persons with lesser economic means (Porter & Novisky, 2017; Turney et al., 2012), and many formerly incarcerated persons do not have substantial economic and familial resources upon release (Middlemass, 2017). Even more, many face stigma in finding employment, particularly people of color (Pager, 2003). Researchers also contend that treatment services may not be as responsive to the specific needs of individuals with a criminal conviction, like the trauma associated with incarceration and a reluctance to share personal problems, among other factors unique to this group (Belenko, 2006; Sachs & Miller, 2018).

Community Variation in Health Care and Rehabilitative Programming

Most studies of individuals on parole have focused on urban samples, and evidence suggests that many do not return to communities conducive to good health outcomes. Individuals on parole often return to urban areas characterized by disadvantage, including high unemployment rates, elevated degrees of poverty, crime, and residential instability, which can exacerbate health care needs (Hipp et al., 2010; Western, 2018).

Researchers argue that place is a key determinant of access to health care—individuals residing in rural areas face more barriers to medical and mental health services than persons living in urban communities (Caldwell et al., 2016; Joynt et al., 2011). A systematic review of the literature found that structural barriers including provider shortages, quality deficiencies, and access limitations were the largest barriers to medical treatment in rural communities (Weinhold & Gurtner, 2014). In fact, differences in the availability of mental health services in rural communities persist, even when controlling for the socioeconomic status and demographic characteristics of the community (Ziller et al., 2010). The authors surmise that the differences are predominately due to lack of skilled care in these communities, and the shortage of providers in rural areas continues to grow (Fields et al., 2016).

Scholars have found similar patterns when studying medical treatment needs and resources available for individuals on parole in rural communities (Wodahl, 2006). Justice systems in rural locales operate on a smaller tax base, and community supervision officers have fewer resources to serve their client base (Weisheit & Wells, 1996; Zajac et al., 2014) and may not have the staffing or time to dedicate to the implementation of evidence-based programming, like cognitive-behavioral programming, which leads to the outsourcing of these services (Salisbury et al., 2019). These findings comport with research which suggests that high turnover and lack of qualified staff is a key impediment to maintaining treatment programs in rural communities, not simply a lack of funding (Edmond et al., 2015; Hipp et al., 2008).

Most of the work to date on health and treatment needs among individuals under correctional supervision has been conducted with general population samples, and very little is known about the unique needs of individuals with a sex offense conviction. There are several reasons why this group makes a unique analytic case. First, most individuals who have a sex offense conviction are mandated to treatment upon release (Kras et al., 2018; Savage & Windsor, 2018). The majority of sex-offense-specific rehabilitation programs follow a cognitive-behavioral therapy (CBT) model, operate in group and individual formats, and are typically accompanied by polygraph testing and supplemental treatment such as medication (Farkas & Miller, 2008). There is emerging evidence to suggest that treatment for this group varies by community. For example, Zajac and colleagues (2014), in a study of paroled persons returning to rural Pennsylvania, found that the availability of treatment programs designed specifically for a population convicted of a sex offense was not commonplace, with only 11 of the 28 counties having programs of this type. The authors also denote that there was little structure to many of these programs that did serve this group (see also Harley & Dunkley, 2018).

Furthermore, persons convicted of a sex offense face tremendous stigma and are subject to unique legal controls (Huebner et al., 2019). Most prominent, in some states, individuals who are convicted of a sexual offense are subject to residency restrictions, which limit where one can live and work (Huebner et al., 2014; Savage & Windsor, 2018; Socia, 2011). Residence restrictions have diminished housing availability for individuals with a sex offense conviction. Emerging evidence suggests that among individuals convicted of sexual offenses returning to urban areas are more likely to move to economically disadvantaged communities upon release, in part due to the stigma of the criminal label and accompanying residence restrictions that limit available housing in more affluent communities (Hipp et al., 2010; Hughes & Burchfield, 2008; Rydberg et al., 2014; Socia, 2011). These same communities often have a dearth of treatment services available (Burchfield & Mingus, 2014). Less is known about the nature of the communities that individuals return to in rural areas, but there is evidence to suggest that individuals are often forced out of urban areas because of residence restrictions (Huebner et al., 2019).

While researchers have documented the extensive needs for and barriers to treatment among parolee populations, little work has compared the treatment needs and access to treatment among individuals in rural and urban communities or considered how a conviction for a sexual offense shapes these experiences. We extend the existing scholarship by documenting the health needs and the distance to treatment among a parolee population and describe how barriers to treatment influence the lived experience among a unique population.

Method

Recruitment and Sampling

Data for this study were obtained through in-depth interviews with 62 people including 59 men and three women (n = 3) on parole for a sexual offense in Missouri.¹ Data were collected in 2010, as part of a broader study on reentry transitions among individuals convicted of sexual offenses (Huebner et al., 2019). Individuals convicted of a sexual offense are subject to numerous restrictions and requirements. All members of the sample are required to register with the Missouri State Highway Patrol and must comply with residence restrictions that prohibit residing within 1,000 feet of a school, park, or day care (see Mancini et al., 2013, for additional information). Individuals convicted of sex offenses are also not allowed to live with minor children, must submit to polygraph testing, and are subject to GPS monitoring, mandated treatment, and other conditions.

To be eligible for the study, participants had to be convicted of a sexual offense, sentenced to a term of incarceration, and paroled. We recruited research subjects using a nonprobability quota sampling procedure to capture the experiences of individuals in various parts of the state, representing economic, social, and geographic diversity, which leads to a final sample of 62 participants (Bachman & Schutt, 2010). Interviews were conducted at five parole offices (n = 43) and one prison (n = 19). Parole offices were strategically selected to represent diverse regional locations in the state, and the prison is the primary state institution housing persons convicted of a sex offense (Creswell, 2012). We include individuals from the prison sample because they were serving a period of incarceration for violating conditions of supervision and had been returned to prison within the previous 6 months. Individuals in the prison sample were asked to reflect on their most recent experience in the community.

The research team recruited participants by visiting parole offices on random report days.² Incarcerated persons were identified by prison personnel, then recruited when researchers visited the prison. Researchers explained the study to participants and obtained consent before interviewing. All interviews were audio-recorded, and pseudonyms were assigned to maintain participant confidentiality. Participants who were residing in the community when interviewed were offered a US$20 incentive to engage in the research. Prison participants were ineligible for the incentive per agency policy. Interviews lasted approximately 60 min on average, and pseudonyms were assigned by researchers using a publicly available list of common names. Further details on the interview sites are provided in Table 1.

Table 1:

Interview Sites—Regional Demographics

Location	Community characteristics				Participant travel
	City population	Housing vacancy rate	Unemployment rate	Poverty rate	Distance traveled (miles)
	City population	Housing vacancy rate	Unemployment rate	Poverty rate	M	SD
Urban
River City	319,294	19.3%	12.7%	21.4%	5.03	3.54
Centerville	108,500	7.9%	6.1%	11.0%	5.78	4.11
Urban and rural
Trainville	10,204	7.7%	5.1%	5.9%	15.48	5.38
Woodland	12,790	11.2%	4.8%	10.7%	19.88	21.18
Rural
Lakeville	17,916	11.3%	6.8%	13.9%	29.84	28.60

Participants were interviewed in a private space at the Missouri Department of Corrections offices using a semistructured protocol modeled after prior research of this type (see Visher et al., 2004). In addition to numerous reentry-related domains, the interview guide included several questions regarding the individual’s sense of community. We asked participants to identify and describe the neighborhoods they lived in or were returning to, including if they were a resident of an urban or rural community. Participants were also asked about mandated treatment requirements, overall physical and mental health, and access to treatment and health care services. The semistructured nature of the interview guide allowed us to ask probing questions and helped respondents freely expand on areas when they felt appropriate.

Demographic information on each of the study sites is presented in Table 1. As displayed, there is substantial variation in the interview locations. Participants were interviewed in one large urban center (River City) marked by high levels of economic disadvantage and one large city (Centerville). The Trainville and Woodland interview sites were located in small cities in counties with a mix of urban and rural populations. The Lakeville site was located in a small city but was situated in a county that was classified as entirely rural. The data presented in Table 1 do not necessarily reflect the home location of participants as many traveled long distances to the parole office. Instead, this information provides more detail on the context of the interview locations and broader detail on the study state overall.

The sample was divided into rural and urban groups by the population of the participant’s home community—as defined by their self-reported address—and geocoded to the census tract. If the participant declined the opportunity to provide address information, data on the respondent’s home residence were retrieved from the Missouri State Sex Offender Registry. Individuals who resided in cities with more than 50,000 or more were classified as urban (n = 37); all other individuals were classified as rural residents (n = 25), which is the same scheme used by the Office of Management and Budget (2010) and in similar prior research (Huebner et al., 2019; Osgood & Chambers, 2000). There is a large literature on the challenges of measuring place arguing that binary categorization can fail to capture heterogeneity in place (Eason et al., 2017; Ellsworth & Weisheit, 1997; Lichter & Ziliak, 2017). We opted to use a dichotomous measure based on population distribution and geographic location given our focus on treatment access, which often centers on distance and accessibility.

Analysis

All interview transcripts were imported into NVivo 11 for coding and analysis. We took a phenomenological approach to analyzing the data, where we could emphasize describing and explaining participant’s lived experiences related to treatment and health. We began by using an inductive coding strategy to identify passages within each interview transcript reflecting treatment and health experiences (Charmaz, 2006). Each participant narrative was coded by at least two researchers. After an initial round of coding researchers compared their analysis for interrater agreement, achieving high consistency across the patterns identified. We then conducted queries and used a focused coding technique to compare urban and rural narratives on key attributes, including sex-offense-specific treatment, substance abuse, and mental health treatment, and general physical health. This approach aligns with the constant comparative method and allows researchers to reliably discern patterns within the data (Glaser & Strauss, 1967). Through this constant comparative process, we achieved saturation of our primary themes and concepts, at which point no new categories or subthemes were discovered and confirming the robustness and richness of the data collected (Charmaz, 2006). We produced analytic memos around prevailing themes after achieving interrater agreement through the consensus-building approach and documenting counterfactuals to dominant themes (Charmaz, 2006; Miles & Huberman, 1993).

Data on health care needs and treatment participation are based on self-report data that were queried as part of the interview, and responses were subsequently coded and compiled into a database. To conduct a graphical analysis of treatment distance, we geocoded participant residences and parole offices using ArcGIS; all participant addresses were successfully mapped using this procedure. We mapped distance to treatment by calculating the shortest distance between the respondent’s home and their assigned parole office along with the street network. This better approximates distance traveled than simply measuring the Euclidean distance. We augment this quantitative analysis by analyzing passages of interviews where participants discuss transportation and distance to treatment. The results presented here are designed to reflect the strongest themes in the data and help facilitate comparisons about how place shapes access to various treatment services among a reentry population.

Results

Health Care Needs and Treatment Participation

Participants had a relatively high prevalence of physical and mental health needs and histories of addiction (see Table 2). In total, 24% of the study sample reported experiencing physical health problems, including diabetes, high blood pressure, hepatitis C, HIV, chronic pain, and other physical maladies. Regardless of where participants lived, they expressed concerns about their health, especially those with multiple aliments, which weighed heavily on their minds. For example, Jeffrey, who lived in one of the largest metropolitan areas of the state, denoted that he had, “three enlarged disks in my neck, carpal tunnel, and scoliosis in my spine.” Paul, who lived in a small city, had a heart attack while in prison and suffered from hypertension and chronic pain. He remarked, “My health has been deteriorating over the years.” Paul, like many others, reported how the incarceration experience aged them mentally and physically and the legacy of poor health continued in the community, particularly as they grew older.

Table 2:

Sample Demographic Characteristics

	Total (n = 62)	Urban (n = 37)	Rural (n = 25)
Demographics
Male	95.2%	97.3%	92.0%
White	76.7%	66.7%	91.7%
Age (years)	38.8 (11.9)	38.7 (10.3)	37.9 (14.2)
Health care needs
Drug use history	74.2%	75.7%	72.0%
Mental illness diagnosis	40.0%	34.3%	48.0%
Physical health	26.3%	37%	12.0%
Treatment participation
Any treatment	91.9%	91.9%	92.0%
Mental health	54.2%	58.3%	50.0%
MoSOP	80.3%	75.7%	87.5%
Substance abuse	37.0%	39.3%	33.3%
Treatment distance (miles)	15.5 (18.3)	9.6 (13.3)	24.5 (21.4)

Note. MoSOP = The Missouri Sex Offense Program. Values in parentheses represent standard deviations.

In addition, 40% of participants indicated that they had received a mental health diagnosis in the past, which comports with estimates from national surveys of incarcerated persons (Bronson & Berzofsky, 2017). Of those reporting mental health diagnoses, nearly half (54.2%) were currently undergoing pharmacological treatment or counseling. In addition, 74.2% reported histories of substance abuse—higher than recent estimates of similar correctional populations (Bronson et al., 2017)—and 37% of these individuals were currently receiving treatment for their addiction.

Finally, 91% of the sample reported active participation in treatment at the time of the interview, including counseling, substance abuse, and mental health services. A unique characteristic of this sample is the requirement to attend sex-offense-specific treatment programming while under community supervision. In Missouri, individuals convicted of a sexual offense are mandated to attend counseling sessions and complete cognitive-behavioral programming as part of the Missouri Sex Offender Program (MoSOP; Missouri Department of Corrections, 2014). Individuals are required to attend weekly group-counseling classes per month, a condition that can continue for the term of supervision and if not completed could result in parole revocation. This program is statutorily designated and includes requirements for treatment, polygraph testing, and other requirements. In total, 75.7% of urban and 87.5% of rural residents report being mandated to attend MoSOP at the time of the interview. Additional forms of treatment can be mandated by a judge or parole officials and can include other forms of cognitive-behavioral programming, anger management, and substance abuse treatment, among other mental health treatment modalities.

As noted, participants reported substantial needs for mental and physical treatment and most had been mandated to participate in individual counseling sessions. The following sections describe the key themes that emerged in the data, including, financial barriers, transportation and access to treatment, and treatment choice. We also include subthemes that document how place contextualizes these experiences.

Universal Financial Barriers

The challenges associated with finding accessible and affordable health care was a nearly universal theme among residents of both rural and urban communities. A first step to accessing health care typically requires the financial means to do so. Very few members of the sample, across communities, had medical insurance and often reported confusion about how to access affordable health care programs. For example, Edward left prison and returned to a rural county far from a metropolitan area with little access to services to treat his acute and chronic health conditions. He describes his experience when he got out of prison:

I had no health insurance and I’ve have had high blood pressure since I was 22 or 23 years old, and high cholesterol and I’ve had a bad back, and this, that, and the other. I had Hepatitis C from sharing a needle and tattoos. I had no means to take care of this.

Edward was eventually able to find someone who would help him navigate the health care system. A friend from church drove him on two occasions to see a doctor in a teaching hospital approximately 100 miles from his house who offered pro bono treatments. He eventually qualified for Medicaid and Supplemental Security Income because of his health care diagnosis; a critical resource given his Interferon treatments, taken for Hepatitis C, without insurance, are estimated to cost US$1,800 per shot.

Access to health care and treatment services is particularly acute in Missouri, at the time of the interviews, as the state has chosen to opt out of the expansion of Medicaid under the Affordable Care Act (ACA), leaving many individuals with a gap in coverage.³ For example, although Phillip, who lived in a suburb of a large metropolitan community, struggled with addiction and mental illness, he was unable to get a bed in an inpatient substance abuse treatment facility as he notes, “I don’t have any insurance.”

Participants found it very difficult to navigate the Medicaid application and the paperwork required to gain disability services felt insurmountable. Matthew returned to one of the largest metropolitan areas in the state, but he did not know how to gain access to health care in the community. He was eventually able to work with a local social service agency that provided medical and dental services for free but not without impediments. He denotes that to access health care he had to provide indigence: “I had to get a copy of my unemployment status, and it’ll last, like seven months. Then I have to reapply again.” While Matthew was able to find assistance, the process of maintaining treatment was a constant battle, and he did not have friends or family who could help assist with the paperwork that was required.

Most participants also denoted challenges with accessing mandated treatment and related correctional programming. Gary’s experience highlights the many and varied requirements of parole. He had a history of drug and alcohol abuse that began when he was 15, returned to an urban community, and was mandated weekly sex offense treatment on top of thrice weekly drug counseling sessions. Like most members of the sample, he juggled his treatment schedule with employment, and although substance abuse treatment was covered by the state, the sex-offense-specific program was out-of-pocket and not covered by insurance. Matthew, Edward, and Gary, like many participants, had chronic health conditions and mandated treatment, yet had little social or financial capital on which to rely. They describe the stressful and often hidden process of accessing health care, all while working to comply with the conditions of parole.

Transportation and Access to Treatment

Distance as a Barrier Among Rural Residents

Access to safe and reliable transportation is a critical resource for individuals returning home to the community (Bohmert & DeMaris, 2018), yet was an enduring barrier to treatment especially for rural participants. Rural participants were more likely to report challenges accessing treatment and denoted distance traveled as a key impediment. Data from the geographic analysis suggest that individuals returning to rural communities traveled further to treatment. As presented in Table 1, we mapped the driving distance from the participant’s home to their corresponding parole office. Overall, individuals in the sample traveled, on average, 15.53 miles from home to their designated parole office. Most treatment providers were near parole centers and some classes, like cognitive-behavioral classes, are held at the office.⁴ However, there was substantial variation in distances traveled for individuals returning to urban and rural communities. Individuals who returned to the two urban communities (Centerville and River City) traveled, on average, 5 miles to their assigned parole office. In contrast, individuals who reported to the parole office in Lakeville, the most rural of the sites, traveled 60 miles round-trip to treatment, 6 times farther than their urban counterparts. Individuals who reported to Trainville traveled an average of 15 miles and Woodland residents traversed, on average, 20 miles.

Figure 1A and 1B further contextualizes distances traveled to treatment. Figure 1A illustrates the commuting distance for individuals living in River City, one of the largest metropolitan communities in the state. In this metro space, individuals lived relatively close to their supervision office, which is facilitated by the presence of 10 offices that serve the population in the community making geographic alignment more possible. There is a dense network of roadways that can be used to travel to the office, and there is an established bus route and light rail transit system in the community.

Figure 1:

Shortest Distance Between Participant’s Home and Probation Office: (A) Urban and (B) Rural

In contrast, Figure 1B displays the sprawl of residences in relation to the rural parole office and the general scale of distance that needed to be covered to meet treatment and programming obligations, with travel distances ranging from 30 to 59 miles one way. The small community does not maintain public transit, and the parole office serves clients from portions of six counties. Two participants live near the city center and report being able to walk or bike around the community, but those residing outside of city limits faced barriers navigating treatment.

Participant narratives reinforced the challenges suggested by the distance calculations. A large difference between communities was that individuals in rural areas lacked access to public transportation, which necessitated car travel of some type and was usually provided by a friend or a family member. For example, Keith lived in a town of approximately 700 people and was over 200 miles from the largest metropolitan area. He was able to see his parole officer in a nearby town approximately 10 miles away, but the mandated MoSOP treatment class was farther away. He describes, “I have to go 33, 34 miles round-trip every week. That’s the closest treatment.” Joseph, who resided in a county with a population of 24,696, indicated that it took 45 min to get to treatment, and he was required to attend 3 times per week. This demand interfered with his ability to maintain full-time employment, as well as the added costs of frequent car travel. Similarly, Brian lived in a town of 298 residents and once a week drove 68 miles each way to mandated counseling sessions. He comments,

I requested a closer group [to my house], but one was not available. I have requested they set up something where it’s easier on me because of my health. It’s been over four years and they haven’t done anything since.

The absence of public transportation in rural spaces, coupled with the distance required to travel to treatment programs, was a challenge for participants who lacked the financial means to buy a car. For example, Roy relied heavily on family for transportation and describes how he made the 23-mile trek into a local town:

By me not having a car, but my sister had a car, my mother had a car, they could give me [a ride] but they had to stop what they’re doing to go take me somewhere. It’s something when I call my PO and tell her I can’t make it to class, she tell [sic] me to get there the best way I know how. They’re not trying to hear that you can’t make it . . . yeah transportation, it’s something.

Participants, like Roy, also had to adhere to residence restrictions which further compounded barriers, which is consistent with other work of this type (Huebner et al., 2019; Socia, 2011). Some participants related intentionally moving outside of city limits to avoid violating residence restriction requirements, which improved the odds of finding residence but complicated access to treatment with new distance and transport concerns.

Public Transportation as a Barrier in Urban Areas

Although rural residents were more likely to report transportation as a barrier, living in an urban community was not a panacea and presented unique challenges. The urban communities in the study had well-developed public transportation systems, but there were financial costs associated and the operating schedule did not always comport with transportation needs. Many participants relied on local social service agencies or their parole agents to provide a free bus pass, particularly during the first few months on parole. Nathan returned to a large urban community and describes, “When you don’t have bus fare, you get like bus tokens, you have to get so many a month from [your officer].” He was never able to get more than 1 month of bus passes at a time and on numerous occasions, vouchers were only given for one or two rides at a time. Nathan had to piece together a daily transportation plan to ensure that he arrived at appointments on time, and other participants reported walking or riding bikes because of the hassle of the bus. The ad hoc nature of this arrangement made travel difficult, and many respondents reported that they were often late for appointments because travel took longer than expected or they missed the bus.

In addition, some urban participants felt that public transportation was stressful and detrimental to reentry success. This concern was oft raised by individuals who were struggling with addictions to substance abuse and had sexual compulsions, particularly individuals who had been convicted of crimes against minor children. Individuals also reported challenges with managing public transit. For example, Patrick lived in the heart of the city after serving 18 years in prison. He reported struggling with deviant sexual cognitions triggered while moving about the city. The city bus was his only mode of public transport and he felt that the closed environment exposed him to negative influences. He stated, “I’ve rode the bus a lot, I didn’t have a car, and you hear guys on the bus talking about sex, sex, sex . . .” Patrick likened exposure to sexual talk on the bus to someone who is an alcoholic and exposed to parties and talk of drinking. He stated,

When you’re around it all the time, it’s, it’s like people with smokes and stuff . . . you’re around it all the time you pick up the habit. Around drinking all the time you’re gonna pick up the habit.

Treatment Choice

Participants returning to urban and rural communities reported challenges in finding treatment that was responsive to their needs and affordable and accessible, which is consistent with extant research (Bronson et al., 2017; Sung et al., 2011). Mental health and other service providers were more prevalent in urban communities but obstacles remained. For example, Martin, who lived in a single-family home with his wife in an urban community of 70,000 residents, notes, “There’s five facilities in [in my community], but only two of them are associated with parole,” which made the availability of programming more limited, particularly given the large number of people in need of services in the community.

The lack of treatment choice was more pronounced in rural areas. In most rural communities, there was a sole treatment provider for the mandated counseling sessions required for individuals with a sexual offense conviction, which did not allow for tailored or responsive treatment. Lack of programming in rural areas is particularly problematic for formerly incarcerated women, who are small in number compared with men but who have unique needs on parole (Beichner & Rabe-Hemp, 2014; Holtfreter & Wattanaporn, 2013). For example, Jennifer, who lived in a rural town in a county with less than 11,000 people, was required to attend mandated group treatment as a requirement of the MoSOP. A female-only group was not available in her small town, as was provided in prison and urban communities. She described being in a treatment group with men as, “It can get very vulgar and very nasty. A couple of guys who like to make little innuendos and be sure they don’t use the anatomical terms.” However, she felt that because she was on parole, and participation in treatment was a requirement, that she had no other choice but to continue to attend.

In addition, the paucity of programming often meant that there were few specialized treatment services available when compared with urban communities, like services for people with co-occurring disorders. Joseph summarizes a common narrative about the challenges of finding a local substance abuse program in his rural locale. He notes, “Yeah there’s not enough available, there’s no NA (Narcotics Anonymous) available, there’s no treatment program available within, you know, just barely less than an hour.” Similarly, specialized treatment, like Sexual Compulsive Anonymous (SCA), which Michael was able to find in his large city, do not exist in rural space, further limiting choices. Because of the substantial distance to the treatment, Joseph and others in rural areas had to choose between opting out of treatment even if it was compulsory, driving long distances to treatment if they had the financial means and transportation, or participating in a proximate, but less specialized that might not address their unique needs.

Discussion

The goal of the current study was to explore the need for and barriers to health care and treatment services among individuals paroled for sexual offenses returning to rural and urban communities. As shown here, justice-involved individuals have substantial needs for health care and mental health services, with prevalence rates consistent with other estimates of incarcerated populations (Bronson & Berzofsky, 2017; Bronson et al., 2017), and most, due to the nature of their conviction, are legally mandated to attend weekly psychological counseling sessions. Nearly all participants report barriers to accessing health care and treatment, as few have insurance nor the economic means to cover the requisite costs.

Although mandating participation in sex-offense-specific treatment is commonplace, this policy poses a great challenge to rural residents. The resource needs for this population are high as participants in the study state are required to attend at least four group-counseling sessions per month throughout the term of their supervision, but the availability of services was limited. The disjuncture between treatment need and available services is common in rural areas. The licensure required to become a therapist is extensive and the pool of providers can be small in rural areas, making services of this type scarce (Weinhold & Gurtner, 2014; Ziller et al., 2010).

The challenge of finding treatment among rural residents was compounded, for many, by a lack of proximate treatment and available transportation. Individuals in the sample returning to rural areas traveled over 6 times the distance to treatment when compared the most urban communities in the study. The distance disparity in commutes is further complicated by a lack of access to public transportation and treatment choice. Urban residents have greater access to transportation and services; however, public transportation poses a unique problem for this population, which comports with other work of this type (Bohmert & DeMaris, 2018). For individuals convicted of sexual offenses, the myriad triggers related to sexual deviance may be more prevalent and harder to avoid in urban settings.

The findings provide important context for understanding access to treatment among formerly incarcerated persons. As a result of the COVID-19 pandemic, there has been an exponential growth in the use of telemedicine; this technology could be leveraged to keep members of the community safe and provide the highest quality health care services for those with little access (Hollander & Carr, 2020). There is emerging evidence that telehealth can be used in community corrections. For example, Subramanian and Shames (2017), in their study of opioid use in West Virginia, describe how telehealth was used for community assessment, particularly for individuals with mental health and substance abuse treatment needs. Goh and colleagues (2016) suggest that partaking in online mental health treatment communities can provide social value for participants and build social support. Given the requirements of mandated cognitive-behavioral treatment among this population, telehealth could assist individuals in rural areas where group counseling is not prevalent and transportation is sparse and in communities where there is little diversity in types of programming available, like for females convicted of sexual offenses.

That noted, there are critical structural and cultural challenges individuals face when obtaining health care in rural communities. For example, broadband internet is readily available in most urban but not rural communities, making health communication more difficult (Parker, 2000). Although beyond the scope of this work, there is also evidence that individuals in rural areas are less likely to disclose service needs to others outside the family unit which can decrease the likelihood of receiving care (Heckman et al., 1998; Logan et al., 2004). Although there have been calls for culturally competent treatment services for rural residents, little work of this type has been conducted, and less is known about the needs of individuals convicted of sexual offenses. Future research and policy should explore how emerging technologies can help narrow social and physical distance to treatment, mitigate the stigma of health services, and reduce service disparities among rural correctional populations.

This work provides new insight into the needs of individuals under correctional control in the community, but several limitations should be noted. First, the study relies on self-report data and may not be representative of the breadth of treatment needs among this population. Future quantitative work that merges correctional and health records would help to more fully document the needs of this population. The results also only reflect the experiences of a sample of individuals convicted of sex offenses returning to select communities in one state. Given the small sample and nature of the analysis, we were not able to consider the unique needs of subgroups of the population, like women, who face unique challenges when returning to rural areas (Beichner & Rabe-Hemp, 2014). Similarly, the urban and rural divide does not capture the heterogeneity in many communities and may not capture the unique experiences of individuals in small towns adjacent to metropolitan regions (Lichter & Ziliak, 2017). This work also focuses narrowly on experiences with treatment. The challenges that many face in access to treatment can also impede finding safe and affordable housing and employment, and factors like crime and economic disadvantage further disrupt the reentry transition (Western, 2018). Scholars should be encouraged to continue developing detailed monographs that highlight the layered and complex reentry experience.

In sum, this research considers the prevalence and nature of health care and treatment needs among individuals paroled for a sexual offense in rural and urban communities. By documenting the extent to which this group of individuals faces challenges, accessing care presents opportunities for scholars, practitioners, and policy makers to understand the problem and work to develop solutions.

Footnotes

Authors’ Note:

Thank you to Ted Lentz for research assistance on this project. The opinions and conclusions expressed in this article are those of the authors and do not necessarily reflect the Department of Justice. This work was supported by the National Institute of Justice under Grant [2008-DD-BX-0002].

ORCID iDs

Beth M. Huebner

Kimberly R. Kras

Notes

Beth M. Huebner is a professor in the Department of Criminology and Criminal Justice at the University of Missouri–St. Louis. Her work focuses on the consequences of a criminal conviction, community and institutional corrections, and public policy.

Breanne Pleggenkuhle is an associate professor in the School of Justice and Public Safety, Department of Criminology and Criminal Justice, at Southern Illinois University. Her research interests focus on prisoner reentry, with emphases on collateral consequences and the social and structural context of post-conviction experiences.

Kimberly R. Kras is an assistant professor in the Department of Criminal Justice at San Diego State University. She earned her PhD in criminology and criminal justice from the University of Missouri–St. Louis in 2014, following a career with the Missouri Department of Corrections Division of Probation and Parole. Her work centers on the study of community corrections organizations and practices, reentry, and desistance from offending behavior, and utilizes quantitative and qualitative methodologies.

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