Caring for over 5 million people in the United States with criminal-legal system involvement (CLSI) poses unique ethical and medical considerations for physicians. Despite the rise of academic medical center partnerships with correctional facilities, no framework to teach learners to navigate the care of patients with CLSI exists. The current literature lacks a clear picture of the motivations, formats, and quality of educational interventions for medical learners providing care to patients with CLSI. This scoping review examines educational interventions and commentaries on caring for patients with CLSI in medical trainees. Using the Arksey and O'Malley framework methodology, the authors searched PubMed, Embase, MedEdPORTAL, and Web of Science to identify English-language peer-reviewed studies. Articles were included if they (1) included medical trainees, (2) involved patients with CLSI and (3) had an educational component. Data extracted included the study type, motivations, and relevant stakeholders. For educational intervention studies, the authors also extracted the learner characteristics, format and content, assessment tools, and study quality. Equity and public health were the most common motivations for CLSI educational interventions. Most published educational interventions were academic health center-correctional facility partnerships featuring clinical rotations among medical schools and residency programs. The most common residency specialties were psychiatry, family medicine, and internal medicine. However, most published CLSI educational interventions relied on exposure to patients with CLSI and lacked explicit curricula or rigorous learner assessments. Our findings demonstrate a perceived need for training regarding the care of patients with CLSI. However, current published educational interventions rely on clinical exposure to patients with CLSI and lack an explicit curriculum and rigorous learner assessments. Development of core competencies utilizing the frameworks of structural competency and prison abolition theory may help inform future educational interventions regarding the care of patients with CLSI.

Many people with histories of criminalized drug use resume using drugs after leaving incarceration, yet limited research explores the specific needs and vulnerabilities of these individuals compared to those who remain abstinent. We examined the relationship between post-incarceration drug use and competing psychosocial needs, as well as these needs' association with views regarding substance use disorder (SUD) treatment. (1) Compare psychosocial needs between individuals with recent drug use post-incarceration and those who were abstinent. (2) Examine which needs are associated with participants' views on the importance of SUD treatment. Among 244 participants with a history of drug use who were previously incarcerated, currently on community supervision, and had elevated risk of HIV, we compared those who used drugs within 30 days post-release (n = 97) to those who did not (n = 147) on health insurance coverage, alcohol use, food security, employment status, housing stability, social support, and depressive symptoms. We analyzed bivariate associations between these needs and the importance of SUD treatment using Wilcoxon-Mann-Whitney and Jonckheere-Terpstra tests. Participants with recent drug use reported higher rates of hazardous alcohol consumption (35.4% vs. 18.1%), food insecurity (58.8% vs. 42.9%), un- or under-employment (61.7% vs. 49.0%), low social support (44.3% vs. 24.7%), and depressive symptoms (50.5% vs. 21.8%). Substance-related problems were significantly linked to higher treatment importance for both groups. Multiple additional competing needs correlated with treatment importance among abstinent individuals. Individuals who return to drug use post-incarceration face greater psychosocial challenges. Results highlight the need for disentanglement of access to services from treatment and the provision of comprehensive services regardless of stage of recovery.

Families of victims of unresolved ("cold case") homicides endure not only prolonged emotional devastation but also chronic exposure to stressors linked to institutional inaction and uncertainty. While previous studies have addressed trauma, grief, and mental health consequences among co-victims of homicide, minimal scholarly attention has been devoted to the physical and physiological impact of unresolved loss, particularly when justice remains indefinitely suspended. This qualitative study draws on in-depth semi-structured interviews with 13 co-victims of cold-case homicides in Israel. Using qualitative content analysis, we examined how participants interpret and articulate perceived connections between prolonged unresolved grief, institutional inaction, chronic stress exposure, and physiological health deterioration. The theoretical framework integrates Ambiguous Loss Theory (Boss, W. W. Norton & Company, 2006), Trauma Theory (Herman, Trauma and Recovery: The Aftermath of Violence-From Domestic Abuse to Political Terror, 1992; van der Kolk, The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma, 2014), and the Allostatic Load Model (McEwen and Stellar, Arch. Intern. Med. 153:2093-2101, 1993). Participants reported a wide range of chronic health problems including cardiovascular illness, autoimmune disorders, chronic pain, hypertension, diabetes, migraines, and disrupted sleep. They consistently attributed their physical decline not only to the trauma of the homicide itself but to the persistent absence of justice and ongoing interaction with inert legal systems, which they described as physiologically corrosive. The unresolved status of their case maintained a long-term state of biological threat activation, manifesting in immune dysregulation, sleep disorders, and severe fatigue. Findings demonstrate that cold-case homicide bereavement extends beyond psychological trauma and constitutes a significant, yet neglected public health burden. The study underscores the need to integrate trauma-informed healthcare within criminal justice responses and calls for official recognition of the embodied consequences of unresolved homicide, both clinically and legally.

Despite efforts to end the HIV epidemic, new transmissions among Black women in the U.S.' Deep South remain disproportionately high. This study examined condomless sex experiences and PrEP non-engagement among Black women in community supervision programs (e.g., diversion, probation, parole) in Alabama. As part of Project E-WORTH South, we used a phenomenological approach and conducted 16 semi-structured interviews to explore factors influencing condom use and PrEP engagement. Participants (n = 16) were selected through criteria-based sampling: Black or African American individuals, female at birth, aged 18 years or older, English-speaking, and current community supervision involvement. Interview transcripts were double-coded using a phenomenological coding technique to identify general themes. The codes were then grouped into themes and subthemes. Analysis revealed four distinct forms of agency that participants employ in sexual health decision-making, mapped along two dimensions: structural constraints/coercion and HIV prevention knowledge/resources. Despite 37.5% engaging in self-initiated HIV testing, 87.5% were unaware of PrEP/PEP existence, with 50% reporting condomless sex. We identified two novel agency forms: deprived agency (knowledge gaps limiting autonomy) and traversed agency (bidirectional override of initial intentions). This study introduces a novel structural agency matrix framework and identifies previously unrecognized forms of sexual health agency among Black women under community supervision. The paradox of high health-seeking behaviors alongside near-zero PrEP awareness reveals systematic information dissemination failures rather than individual barriers, demonstrating need for matrix-informed interventions that simultaneously address structural constraints and knowledge gaps.

Adverse Childhood Experiences (ACEs) and Positive Childhood Experiences (PCEs) are each independently associated with a range of adult outcomes, including mental health, substance use, and criminal justice involvement. However, few studies have examined how the balance between these experiences influences outcomes. This study explores the predictive utility of a PCE:ACE ratio. Unlike previous measures of resiliency and risk protection scales that treat risk and protective factors as parallel dimensions, the ratio is population-level heuristic intended to capture the relative balance of positive versus adverse experiences using a single relational metric. Using data from a representative sample of 1,203 adults in Northern Ireland, participants completed validated measures of 13 ACEs and 10 positive childhood experiences (PCEs) A weighted PCE:ACE ratio was calculated, and participants were categorised into high, moderate, or low ratio groups. Findings showed that a higher ratio was significantly associated with reduced odds of arrest, incarceration, school exclusion, substance use, and mental health diagnosis, even after adjusting for age, gender, and deprivation. Those in the low-ratio group had the highest rates of adverse outcomes. While the ratio offers an intuitive and accessible framework for understanding developmental balance, limitations include the potential for oversimplification of distinct ACE-PCE profiles. These findings support the feasibility of a ratio-based approach that standardises balance rather than the independent accumulation of risks and strengths, and suggests that a stronger balance of protective experiences may buffer the impact of adversity. Further research is needed to explore threshold effects and interaction dynamics. However, the ratio provides a useful metric and sound basis for capturing population health and the extent to which public investment is tipped in favour of positive or less positive outcomes.

Adults in the criminal justice system are disproportionately more likely to use alcohol and drugs compared to the general population. Legally mandated alcohol and drug treatment orders have been proposed as an alternative to prison. However, little is known about how treatment orders affect the health and well-being of this population. A systematic review and meta-analysis. We searched 14 electronic databases (last searched November 2023) for studies comparing adults in legally mandated non-custodial drug and alcohol treatment orders to those receiving mandatory treatment orders or usual care.Global functioning, quality of life, drug or alcohol use measures, dependence severity, depression/anxiety outcomes, family member/significant other outcomes, and adverse events were selected based on a minimum core outcome set.We performed a meta-analysis using meandifferences and risk ratios with 95% confidence intervals. We assessed the certainty of the evidence using GRADE.Equity-related factors were mapped to the PROGRESS-plus framework. People with lived experience provided input throughout the review process. From 6917 records, 11 studies involving 4643 individuals (70% men; seven randomised controlled trials (RCTs)) met the eligibility criteria. All studies were conducted in high-income countries and involved drug and alcohol courts.The main outcomes of global functioning and quality of life were not reported. Poor reporting limited the meta-analysis. There were nodifferences between the groups receiving the intervention and those in the control group regarding number of positive drug screenings (MD -0.80, 95% CI -3.60 to 2.00, 10 participants, p = 0.58); depression (RR 0.93, 95% CI 0.78 to 1.10, 1533 participants, p = 0.38); or serious adverse events (RR 0.33, 95% CI 0.02 to 6.65, 10 participants, p = 0.47). We judged the evidence as very-low.The equity criteria most frequently reported were age, sex and race/ethnicity. The evidence is insufficient to draw judgements about the effectiveness of treatment orders for health and well-being. We found no evidence relating to global functioning, quality of life, anxiety, and outcomes specific to family members or significant others. High-quality RCTs are urgently needed.Future studies should involvepeople with lived experience in the design and conduct of new trials. Study protocol registration. The protocol for this study was registered on PROSPERO: CRD42023484923.