Trialing Over-the-Counter Mild Pain Medication Access in Queensland Prisons: The Experience of Women Prisoners

Evonne Miller, Lisa Scharoun, Jane Phillips, Roslyn Williams, Jane Hwang, Abbe Winter, Linda Carroli, and Lisa Nissen

Abstract

In Queensland, Australia, adults in custodial facilities do not have discretionary access to over-the-counter (OTC) medications for mild pain relief and management. This study evaluated a trial allowing prisoners in male and female units at a regional Queensland correctional facility to purchase OTC medications from the prison store. The trial aligned with human rights legislation, international obligations, and the requirement for community equivalence of health care for prisoners. Queensland is the first jurisdiction in Australasia to undertake such a trial. We analyze the results from focus groups and surveys, comparing male and female prisoner experiences, by applying a gender impact assessment to examine pain management as a gender and health rights issue. Pain is gendered, and women’s pain is often downplayed, not taken seriously, or not treated appropriately. Prisoners reported that being able to manage their pain relief gave them agency and decision-making ability that affirmed their human and health rights while living in a controlling environment. While this initiative has a positive impact on gender equality—because women are better able to self-manage pain—there are continuing opportunities to improve women’s health care and address challenges of equivalence and the gender pain gap in prison systems.

Introduction

Prisoners often have complex health needs and high rates of physical and mental illnesses, substance abuse, chronic illness, and other conditions that can benefit from ready access to pain relief.[1] While access to self-managed over-the-counter (OTC) mild pain medications (e.g., paracetamol) is standard practice in many American and European prisons, across Australasia medications are dispensed by prison health staff. Prisoners are generally unable to keep any medications in their possession.[2]

When the Queensland government introduced human rights legislation in 2019, statutory bodies were compelled to align their practices with the new law’s provisions, including health rights alongside gender-based equal opportunities and anti-discrimination, enshrined in federal and state laws and international agreements.[3] Collectively, these frameworks provide broad guidance, rather than prescriptive rules, for upholding the principle that prisoners should have access to health care, including pain relief, equivalent to that of the wider community.

We document the impact and experience of an OTC medication trial in a regional Queensland prison, addressing gendered experiences of pain and pain management. The medications—paracetamol (a simple analgesic) and ibuprofen (a nonsteroidal anti-inflammatory drug)—do not generally require a prescription in small quantities and can be sold in non-pharmacy settings, including supermarkets. Previously, prisoners had access to these medications only via prison health center clinicians. The trial permitted limited amounts of paracetamol and ibuprofen to be purchased (at a cost of ~A$1 for a pack of 10) from the prison store (or “buy-up”), weekly in the women’s prison and fortnightly in the men’s prison. The “buy-up” system—also known as the prison store—allows prisoners to purchase approved personal items, such as snacks and toiletries, using their account funds. While this OTC medication trial addressed the rights consideration of equivalence of health care, the trial evaluation raised gender impact and mainstreaming considerations. Gender plays a role in experiences of the legal, justice, and corrections systems. We examine how women in prison experience pain, and the impact of the OTC medications trial. Focusing primarily on prisoner voice, we present findings from the trial evaluation (via focus groups and surveys) and apply gender impact assessment (GIA) ex-post to examine the difference between male and female prisoner participant experiences.

Women in prison and their pain experience

Women are a significantly smaller proportion of the prison population than men. The 2023 prison population in Australia was 41,929 people, of whom 8% were female.[4] Furthermore, Aboriginal and Torres Strait Islander prisoners accounted for 33% of all prisoners, of whom 9% were female.[5] Nationally, the median age for all female prisoners was 35.5 years, and 36.3 years for males. In Queensland, the total prison population was 10,226, of whom 10% were female. Aboriginal and Torres Strait Islander peoples accounted for 37% of Queensland’s prison population.

The Queensland Human Rights Commission (QHRC) identifies a high incidence of mental and chronic health conditions among female prisoners.[6] According to the QHRC, “fewer female prisoners than males reported they had been able to readily see a GP or nurse while in prison.”[7] A high percentage of female prisoners (87%) have experienced gender-based violence and trauma during their lives, which can correlate with mental health and chronic health conditions.[8] Indigenous women, who are overrepresented in the prison population, can be disadvantaged in health care in prison despite the “equal treatment” principle.[9] Due to health care inequity in the broader community, for some prisoners, access to health care in prison can be more consistent.[10]

Critical questions for authorities in the OTC medication trial were whether prisoners could be trusted to independently manage OTC medications and whether risks could be sufficiently mitigated or self-managed by prisoners. Managing pain in a way that addresses human rights within prisons requires the navigation of risk and trust, which for some authorities can be a trade-off. In Australia (and globally), pain is a topical gender and health issue, with the Victorian state government opening a public inquiry into women’s pain and a major pharmaceutical company presently raising awareness about the “gender pain gap,” recognizing gendered specificities in the treatment and causes of women’s pain.[11]

The OTC medication trial as a step toward equivalence of health care

The evaluation of the 2022 Queensland prison trial addressed the benefits and challenges of changing how prisoners access paracetamol and ibuprofen as unscheduled OTC medications. Paracetamol is Australia’s most widely used pain medicine, with 65 million packs sold in 2021 from supermarkets, pharmacies, convenience stores, and toilet vending machines.[12] Paracetamol is sold in a pack of 20 outside of pharmacies, and in packs of up to 100 tablets in pharmacies. It is widely available and low cost, making it a convenient option for people to self-treat pain without a doctor’s appointment or prescription. When taken as recommended, paracetamol is safe. However, it can be dangerous at high doses, causing acute liver toxicity. Australia’s Therapeutic Goods Administration recently reviewed access to paracetamol in the community due to concerns about intentional overdoses and decided to reduce the pack size of paracetamol starting in February 2025.[13] Even with mildly increased restrictions, paracetamol remains highly accessible and available to people in the broader community, raising considerations of equivalence for prisoners.

Internationally, OTC medication access occurs in prisons in the United States (since 2003), Canada (since 2014), and the United Kingdom (since 2015).[14] This provides prisoners with better access to consistent and self-managed pain relief, reflecting human and health rights as per the 1955 Nelson Mandela Rules (updated in 2015, where prisoners are entitled to health care commensurate with that available in the community) and addressing known challenges in prison health care.[15] Standard practices in prison, such as strip searching, can deter women from seeking medical and counseling support.[16] The Bangkok Rules, adopted by the United Nations in 2010, specifically refer to female prisoners and assert that gender equality is not achieved by treating female and male prisoners the same.[17] Queensland’s Human Rights Act of 2019 states that “every person has the right to access health services without discrimination.”[18] Because adults can easily consume paracetamol and ibuprofen from supermarkets in the community, allowing access to these medications during “buy-up” aligns with international, national, and state obligations.

The trial emerged from discussions with Prisoner Advisory Committees as part of the 2018 Offender Health Services Review and 2021 Health Consumers Queensland consultations. Among its recommended changes, the 2018 review called for clinical service redesign to increase efficiencies in medications management. This specifically referred to the development of “appropriate policies and processes for prisoner self-medication, targeted at appropriate prisoners and applying only to medications deemed safe and not at risk of diversion within correctional centres … [including] ready access to PRN medications (e.g., analgesics that, in the community, are available ‘over the counter’ without a prescription).”[19] The trial was subject to risk mitigation and safety guidelines that are consistent with the recommended use of OTC medications. In the trial this included limits on amounts available for purchase and storage (10 each of paracetamol and ibuprofen) and measures to improve prisoner health literacy.

Health and pain control medication in prison settings

Pain management is a significant issue in prison. Epidemiological studies show that people in prison experience complex health issues, with some of the worst health outcomes of any population group across all health domains.[20] They experience higher levels of physical and psychiatric illness compared to the general population, and stressors imposed by incarceration further contribute to negative health outcomes.[21] They also experience health issues as a result of incarceration, including the development of health problems typically associated with aging that can benefit from pain relief.[22] Consequently, medical services are in higher demand in prisons than in the broader community.[23] The recognition of prisoners’ entitlement to the same level of care available in the community underlines the provision of health care services in carceral settings.[24] Access to medicines and medical products is a critical dimension of health rights and quality of care, particularly in relation to pain management.[25]

Research addressing the availability of pain control medication in prison settings tends to focus on pain management in cases of illnesses such as cancer or acute injury, rather that the treatment of day-to-day pains such as menstrual pain or toothache.[26] It is also acknowledged that males are less likely to proactively manage their health care.[27] Other research focuses on medication-prescribing for older prisoners, as well as the frequency of prescribed analgesia in prison.[28] It does not tend to explore in any detail the supply of OTC substances such as paracetamol and ibuprofen, noting that access to such medication is restricted and available through application to custodial personnel in the Australian context. Available research also raises the tension between security and patient-centered care, trust in prison health care delivery, and workload implications.

Women’s pain can also be treated differently in health care settings (it can be dismissed) and is a topic identified as requiring more research.[29] As Kimberly Templeton explains, “women are more likely than men to experience a variety of chronic pain syndromes and tend to report more severe pain at more locations than do men.”[30] International research indicates that women’s pain is frequently downplayed, mistreated, psychologized, and disregarded due to the proliferation of gender stereotypes and biases.[31] Emily Bartley and Shreela Palit’s study of 19 European countries found that significant gender pain inequalities are evident across Europe, referring to a “gender pain gap.”[32] Inequality, stereotyping, and bias in care, as well as the undertreatment of pain, are also reported in studies of gender, race, and pain, indicating a need for greater intersectional and gender awareness of equity in health care.[33]

Further research is needed on women’s pain management experiences in prisons. A rights-based approach is responsive to needs that Shirley Gabel describes as “duty bearers hav[ing] a clear-cut duty to meet needs and if they do not, are violating the rights of rights holders.”[34] In the Bangkok Rules, women’s specific rights include access to gender-appropriate health care. A 2023 UK National Health Service review of health and social care in women’s prisons found that gender-sensitive health and social services are not consistently available and that current service provision is not fit for purpose.[35] While not addressing pain specifically as part of gender mainstreaming, the Council of Europe recommends “a gender-specific framework for health care in women’s prisons, which emphasises reproductive and sexual health, mental health, treatment for substance abuse and counselling victims of violence.”[36] Recognition of gender equality and mainstreaming is intrinsic to a rights-based approach. We compare the female and male prisoner experience, applying GIA principles as a framework to examine the impact of an OTC medications trial.

Methodology

This study evaluated a 2022 trial allowing prisoners in female and male units at one regional Queensland correctional facility to purchase OTC medications in the “buy-up.” The evaluation of the trial was undertaken by an interdisciplinary team of design, psychology, nursing, and pharmacy researchers. Experiences of the trial were evaluated through focus groups involving 37 prisoners (16 women and 21 men) and paper surveys with 75 prisoners (23 women and 52 men) in the facility. The average age of participants was 36.5 years for females and 44 years for males.

Three researchers conducted qualitative research in person, with one leading conversations while others took written notes. Written notes were analyzed using inductive thematic analysis to reveal the themes that were common across participant experiences.[37] A paper survey was distributed to prisoners, who then returned them by post. The survey posed questions about the frequency, type, and location of pain experienced by prisoners, behaviors and preferences in relation to pain relief medication and management, and their perceptions of the change of policy. The correctional facility also provided access to internal records of OTC medication purchasing. The research team aimed to understand user experience by adopting a “view from below” approach to explore issues of power and rights in prisons, recognizing prisoners’ voices and enabling prisoners to share their stories and experiences.[38]

GIA is applied as a lens for discussing the thematic findings acknowledging the gender dimensions of health rights in relation to pain management in the prison context.[39] GIA can be applied to policy, program, and regulatory interventions to evaluate how they address a particular issue and the extent to which they contribute to gender equality.[40] This approach has affinity with rights-based approaches given that rights are gendered, and women’s rights and equality are articulated in charters and rules. Gender impact was not examined when the OTC medication trial was developed, and we apply it ex-post as a useful evaluative framework. GIA specifically focuses on the gender relevance of a policy or program initiative, addressing its direct and indirect impact through differences in access to resources. It particularly stresses the use of gender-disaggregated data to examine gender inequalities, including access to resources such as health and the exercise of fundamental rights on the basis of gender.

Findings

Prisoner participants were positive about the trial, valuing the trust placed in them to manage their own pain relief. As discussed below, thematic analysis revealed two core themes—agency and risk—as critical dimensions of trust that have specific implications for women. The first theme highlighted the importance of the initiative in affirming agency, dignity, and self-reliance, with access to additional health resources better equipping them to manage their pain. Participants indicated not only that they felt trusted but also that they can be trusted. In focus groups, female prisoners said they were “so grateful for it,” while the male prisoners said that it took the “unnecessary aggravation out of the system, improving prisoner dynamics because pain was better managed.” In both focus groups and surveys, prisoners reported that being able to self-manage access to pain relief meant that they did not need to continually contact officers or the prison clinic to seek treatment for common ailments (toothaches, headaches, sore muscles, period pain), which was positively transformative. The second main theme reflected the understanding of and being realistic about risks associated with the initiative and provision of equivalent health care.

Theme 1: Giving back agency, self-reliance, and dignity

Records retained by the prison show purchase patterns over a 12-month period among the ~800 male and ~200 female prisoners. Overall, 9,372 packets were purchased—nearly 3,000 packets each of paracetamol and ibuprofen in the male prison, and just under 2,000 packets of each in the female prison. This averages to about 9.5 packets per person in both prisons over this time frame, or less than one packet per person per month. On average, female prisoners purchased about 20 packets per year and male prisoners purchased about 7.5 packets per year. Sales started at around 100 packets each of ibuprofen and paracetamol per month in May 2022, slightly increasing to ~160 per month in the women’s prison and doubling in the larger men’s prison to ~250 packets per month a year later, in May 2023. Because prisoners reported some difficulties in obtaining pain relief from clinicians, this may partly account for the increase. No clinical or custodial adverse events were reported from the trial.

The purchase figures align with the survey responses on frequency of OTC medication use. The overall figures reflect the survey findings in which women reported more regular use of OTC medication. A higher percentage of female participants (48%) than male participants (34%) reported using pain medication every day. A slightly higher percentage of female participants (22%) than male participants (20%) reported using pain medication once or twice a week. However, a higher percentage of men reported using them several times a day, even though they otherwise reported less frequent use of pain killers. A higher percentage of women (96%) than men (83%) indicated that they had purchased OTC medications from the prison store, and 26% of females and 19% of males reported using medications more often after the OTC medications became available for purchase. Most participants (57% of females and 69% of males) reported that their medication use has not changed, indicating that the availability of medications is not driving their use.

Survey results indicate high approval of the initiative, with most female (78%) and male (75%) participants responding that the initiative is a good idea. Participants feel that the processes used by health care staff for assessing whether a prisoner is eligible (70% of females and 71% of males) and then monitoring the use of mild pain medications (61% of females and 56% of males) are working and appropriate. However, more women (70%) than men (33%) find the eligibility screening process—in which assessments are performed by individual clinicians to manage perceived risks—to be restrictive.

Participants agreed that having a pack of paracetamol or ibuprofen in their cell provided significant peace of mind, enabling them to proactively manage their own pain via a process that was “handy, convenient, and cheap.” They greatly valued the dignity of being able to manage their own pain medications, as this change restored their sense of agency and control, enabling them to “doctor ourselves” and “giving back our self-reliance, control, and power—to look after ourselves and initiate self-care.” The availability of OTC medication was seen as a privilege, which “gives more benefits than not” as “no one was mis-using it” and it was a “no brainer.” Both female and male participants liked the convenience of being able to make decisions for themselves and not having to wait for consultations with prison medical staff. As one participant explained, “When I have an ache it is easily accessible. And I don’t have to wait or I’m not in pain for long time.” This is particularly important at night because the medication “can [be taken] during night when nurse not here.”

Female participants expressed gratitude and relief, describing how they lived with period pain and greatly appreciated the “independence of it, to take when needed, and being trusted to self-medicate.” Participants consistently reported that 10 paracetamol was insufficient and that they were “running out.” Consequently, the ability to have access to more would be appreciated, but the dominant feeling was gratitude for being trusted to independently self-medicate. As one participant described, it is “AMAZING. We are so very appreciative and grateful of this change.” Female participants reported that some clinicians did not trust them to take pain medications safely, which they found to be patronizing and offensive because “we are not children, we are adults.” Many female participants described living with injuries, chronic pain, and menstrual-related pain and reported that they were often treated with “mistrust, and dictation of what we can and can’t have” from some of the prison clinicians. In having to seek permission to take paracetamol, both female and male participants expressed their sense of disempowerment and infantilization, which is more commonly experienced by women in health care settings.

Women more strongly support the trial, with 100% of female participants and 85% of male participants indicating that prisoners should be able to buy OTC medications from the prison shop. Participant responses to questions of agency indicate that access to OTC medications not only positively impacts their sense of well-being but also contributes to a peaceful atmosphere in the prison (96% of females and 73% of males). Male participants used words such as trust, choice, freedom, and control to describe their experience, indicating that agency has an overall benefit for prisoner well-being. As stated by one male participant, “It gives us a little control over our health, and as an extension, our mental health.” In contrast, women used terms such as gratitude and appreciation to explain that they value the agency of managing their pain without clinical intervention, which potentially reflects their clinical experiences. Almost all (100% of females and 81% of males) agreed that rolling out the initiative across the state would have a positive impact on prisoners’ ability to self-manage pain.

Theme 2: Being realistic about the risks

Both female and male participants were pragmatic about the risks of overdoses and hoarding, which they saw as minimal because prisoners can access only ~10 pills at a time. Officers monitored and searched cells regularly, and prisoners asserted that they understood how to responsibly take pain medications. Both female and male participants stressed that as adults (“not kids”) they are capable of managing medications; as two female participants explained, “if you are old enough to go to jail, you are old enough to take Panadol” and “I am 41 years old and know how to take prescription drugs.”

Participants also affirmed the importance of having access to OTC medication and noted that they should not be punished or denied because of others’ misuse. A female participant said that “we should be able to have a packet of Panadol in our rooms in case of headaches or mild pain, if things worsen go to medical but not sure about midnight pains so we’ll need Panadol coz probably no nurse or doctor available at midnight.” Participants also said that trading was not an issue, identifying a comparatively low risk of pressure to sell, trade, or share their supply (83% of females and 65% of males said no). The quantities purchased (average of 9.5 packets per person per year) also indicate that purchasing habits are consistent with personal use.

Approximately half (48% of females and 46% of males) said that they were aware of the potential for “bad outcomes” (overdosing, hoarding, or on-selling medications), and the vast majority said that it was “not too risky to let prisoners buy mild pain medications through the prison shop” (78% of females and 90% of males). Although participants were aware of potential “bad outcomes,” they regard the availability of OTC medication as low risk. In focus groups, few recalled seeing prison-specific safety material but noted that there was standard health and safety information in the pack, while in the survey most (78% of females and 75% of males) said that sufficient safety measures have been implemented. Prisoners understood risks; one participant explained that “an overdose is a slow death” and that taking only two is ingrained. Participants suggested including information in the “arrival book,” supplemented by very simple print and in-cell prison television content. Given that some prisoners cannot read, all recommended the display of low-literacy informational posters that “dumb it down.”

Participants indicated that the prison has appropriate systems in place to manage the risks (100% of females and 71% of males), even though women in particular experience the eligibility screening process as restrictive. Participants also expressed distrust of the system; they are concerned that access to OTC medication could be revoked. Participants greatly value being able to access OTC medications through buy-up and recommended expanding the selection to include a “health and well-being” section that offers antacids, vitamins, personal care, first aid, and other everyday items.

Gender-disaggregated findings

This study finds that although both female and male participants value and rely on the availability of OTC medications—which has enhanced prisoners’ agency and sense of worth—gender-based differences remain evident in their experiences of pain and OTC medication use. A higher proportion of women than men purchased OTC medications and in higher quantities, reflecting a greater need among women for OTC medications. Women reported that the eligibility screening was restrictive or difficult. This is possibly indicative of a gender pain gap and biases in health care, but requires further research. Women described their experience in terms of “convenience” and “gratitude.” Both women and men want to be treated like adults, not children, which is a meaningful assertion of capability. Although both women and men would like access to more OTC medications, the women’s prison provides more frequent buy-ups than the men’s prison. This potentially highlights unmet need among female prisoners, some of whom report long wait times to consult clinicians. Participants also indicated that they are not always provided with OTC medications by clinicians, particularly if they have purchased them in the buy-up. However, statewide policy requires that the prescription of pain medications occur irrespective of their availability via the prison store.

Discussion

Prisoner experiences with OTC medications highlight the interplay of rights, gender, risk, and trust in the provision of equivalent health care.[41] From both a rights and a gender perspective, this study addresses a health rights issue that has not received sufficient attention in relation to incarcerated women. Clear differences between female and male OTC medication use suggest that greater gender and intersectional sensitivity could improve the health impact of this intervention. The granting of the same quantities of pain relief for both women and men may not reflect women’s pain experiences, their need for and capacity to self-manage OTC medications, or the adequacy of prison health care.

Internationally, the application of the Bangkok Rules resulted in the HM Inspectorate of Prisons in the UK introducing gender-sensitive “expectations” in 2014.[42] Policies and programs that seek to address pain management must also consider systemic gender biases in their application. Evidence possibly indicates that a gender pain gap may be amplified in the prison setting due to a gendered burden of illness, the tendency of males to neglect their health care, and the complex health needs of prisoners.[43] Applying GIA as a framework for this discussion foregrounds gender awareness in evaluating the provisioning of pain relief in prisons while also indicating opportunities for further learnings in the continuing alignment with human rights obligations.

Female and male prisoners are held in separate facilities and access health care within those settings. Survey responses indicate limited access to clinicians, with participants reporting long wait times and restrictive eligibility screening, contributing to a lack of agency and a sense of powerlessness. The convenience and affordability of OTC medications available through buy-ups support prisoners’ capabilities for self-care and control.

Among female participants, reports of chronic and menstrual pain highlight how pain management needs may differ by gender. These patterns suggest that existing systemic disparities in how women’s pain is recognized and treated in the broader community may also shape health experiences in prison. This disparity—often referred to as the “gender pain gap”—is likely intensified in correctional settings, where trauma, violence, and limited access to appropriate health care are more prevalent.[44]

The availability of OTC medications in the buy-up does not prevent prisoners from accessing paracetamol and ibuprofen for free through health center processes, which aligns with the Nelson Mandela Rules. Providing prisoners with easier access to consistent and self-managed pain relief aligns with access in the broader community. For prisoners, this equates to being “treated like an adult” and exercising the freedoms and choices that adulthood confers even when incarcerated. Given that prisoners express some dissatisfaction with access to medical care within the prison, the availability of OTC medications is seen as addressing a gap. Further research into prison health care, particularly from a gender perspective, is warranted because it can potentially lead to more gender-sensitive approaches that address gender bias and women’s rights in clinical practice, a policy learning for prison systems seeking to implement similar programs targeting health literacy and agency.

Our findings indicate that prisoners view themselves as capable decision-makers, knowledgeable of the risks, and deserving of trust to manage OTC medications. Prisoners in this study were pragmatic about the risks of overdoses and hoarding, arguing that they are not only aware of risks but also able to manage their pain and safety. The relational dimensions of trust (which involves tensions of agency and risk) was also acknowledged: “the prison needs to give inmates more trust.” Other research also reports how effective prisoner-patient pain management is challenged by the perception among staff—and among the public at large—that prisoners report fictitious pain to obtain analgesia for secondary gain rather than actual pain relief.[45] Because pain is often unseen and misunderstood, staff may react to this perceived lack of prisoner credibility by restricting the prescription of certain drugs, requiring evidence beyond self-report to verify suffering, and expressing anger and frustration when prisoners are seen as deceitful or manipulative.[46]

This study provides important evidence to assuage fears regarding the potential negative outcomes or abuse of health-related autonomy given to prisoners, as well as insights into the secondary benefits of such empowerment, such as reduced animosity toward custodial staff and mood regulation. A growing body of evidence encourages a paradigm shift toward recognizing prisoners as trustworthy and capable agents in managing their own health care and underscores the value of providing equivalent health care in prisons.[47] A rights approach calls for gender mainstreaming that builds trust and mutual recognition of system actors. However, prisoner agency remains contingent on prison staff and the authority and institutional legitimacy that they represent.[48] In prison settings, where prisoners experience disempowerment, prisoners are not confident that their requests for pain management will be addressed or taken seriously by staff.

Prisoners demonstrated awareness of the risks and concerns in relation to the relaxed availability of paracetamol and ibuprofen. For example, female participants suggested that education be provided about the safe usage of these medications. As the government of Queensland extends this initiative to other prisons across the state, it is essential to develop a complementary suite of resources on pain education and management to accompany its implementation.

Women’s more frequent use of OTC medications since they were made available for purchase indicates gendered differences in pain experiences and management. It could also indicate that women’s pain had been undertreated prior to the trial. Barriers to timely access to medical care are created by the tension between the security needs of the institution and the delivery of patient-centered care.[49] This is evident in the cultural conflict between correctional and health care systems and has been highlighted in relation to recent public health challenges such as COVID-19.[50] In recognizing the challenges of providing equivalent care in prisons and the complex health circumstances of many incarcerated people, Gérard Niveau argues that a better strategy is to exceed community standards rather than compromise them.[51]

With the availability of OTC medications, the self-reported prisoner experience shifted from being controlled to being trusted. For some, this conferral of “adultness” was appreciated, although it also plays into fears that the access might be revoked. In relation to gender, trust is particularly challenging, for researchers have found that female patient reports of pain are regarded as less trustworthy or more exaggerated.[52] This and other types of invalidation of women’s pain by clinicians results in women’s loss of rights.[53] The concept of equivalence of health care is not self-evident, as the organization of health care can necessitate adaptions in response to the prison setting.[54] Further, Sacha Kendall et al. argue that “equal treatment” is insufficient for equitable health care given that some groups carry a higher burden of illness.[55] Health care providers need to understand why women prisoners are using OTC medications more frequently than men. The study findings suggest that equivalence and equal treatment benefit from sensitivity to gender and intersectional and individual circumstances, while patient-centered and trauma-informed approaches ensure that women have the necessary access to resources.

Conclusion

This evaluation of the OTC medication trial in Queensland prisons has shown the value of enabling access to simple analgesics commonly used for minor pain conditions (e.g., tension headache, menstrual discomfort, and musculoskeletal pain), alongside strict and medically informed safety and risk-reduction strategies in terms of the quantities permitted. It is one pathway to realizing the human rights obligations of state government agencies contained in legislation and international agreements.

As well as enabling prisoners’ independent pain management and health literacy, the evaluation suggests a broader potential benefit from the reduced reliance on medical and nursing services for minor and low-acuity conditions, although more research and data are needed to quantify this potential impact. This evaluation has shown that enabling access to OTC medications that are commonly available in the community is a positive step toward health rights, equivalence, and improving prisoner health care and health literacy. It demonstrates that prisoners are responsible and can be trusted to manage these OTC medications, as no problems or adverse events were reported in the evaluation. This is a strong indication that rights and risks can be managed within prisons to provide equivalent health care.

Here, we have adopted an explicit gender impact lens to highlight both the importance and limitations of the “equivalence” of health care requirement. We suggest that, alongside global human rights initiatives, gender impact should be consciously considered in the development of prison health care initiatives to ensure that biases within both the correctional and health systems are addressed. The significant difference between female and male OTC medication requires further research. Just as COVID-19 and HIV/AIDS pressured prison health systems to be more responsive and adaptive, this trial provides policy learning to improve prison health care’s alignment with rights.[56]

This study highlights the need to integrate gender awareness into prison health care and health promotion as an essential component of a rights-based approach. “Equivalence” should not mean the reproduction or amplification of systemic biases in the prison system, which potentially results in a gender pain gap; rather, it requires a more reflexive synthesis of gender, intersectionality, and rights in the prison context. Gender mainstreaming and gender impact assessments can enable more targeted strategies to advance gender equality in prison health care. While this initiative responded to human rights obligations and greatly benefited women, it was not introduced with an intentional consideration of gender. Prisoner voices—as the view from below—make gendered pain experiences explicit. The issue of women’s pain and pain management in prisons also warrants further research addressing patient-centered and trauma-informed considerations.

Acknowledgments

We are grateful to Queensland Health’s Office for Prisoner Health and Wellbeing for driving the development and implementation of the OTC initiative (which was approved by the Prisoner Health and Wellbeing Leadership Group) and for funding this evaluation, and to Queensland Corrective Services for enabling access. We would also like to thank the staff and prisoners at the case study site for welcoming us. The lead author acknowledges and thanks Conor Brophy, chair of the Queensland University Human Research Ethics Committee, for an invaluable conversation about the project’s approach, processes, and methods and for feedback that greatly facilitated and streamlined the ethics application and process.

Funding

This project was funded by Queensland Health’s Office for Prisoner Health and Wellbeing.

Ethics approval

Formal research ethical approval for the project was granted by Queensland University of Technology (#6631) and subsequently approved by Queensland Corrective Services.

Evonne Miller is director of the QUT Design Lab at Queensland University of Technology, Brisbane, Australia.

Lisa Scharoun is head of the School of Design at Queensland University of Technology, Brisbane, Australia.

Jane Phillips is head of the School of Nursing at Queensland University of Technology, Brisbane, Australia.

Roslyn Williams is manager of the Office for Prisoner Health and Wellbeing, Queensland Health, Brisbane, Australia.

Jane Hwang is a researcher at the Justice Health Research Program, School of Population Health, University of New South Wales, Sydney, Australia.

Abbe Winter is a researcher at the QUT Design Lab at Queensland University of Technology, Brisbane, Australia.

Linda Carroli is a researcher at the QUT Design Lab at Queensland University of Technology, Brisbane, Australia.

Lisa Nissen is director of the Health Workforce Optimisation Program at the Centre for the Business and Economics of Health, School of Pharmacy, University of Queensland, Brisbane, Australia.

Please address correspondence to Evonne Miller. Email: e.miller@qut.edu.au.

Competing interests: The authors were funded by Queensland Health’s Office for Prisoner Health and Wellbeing to undertake the trial evaluation.

Copyright © 2025 Miller, Scharoun, Phillips, Williams, Hwang, Winter, Carroli, and Nissen. This is an open access article distributed under the terms of the Creative Commons Attribution-Noncommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited.

References

[1] Australian Institute of Health and Welfare, The Health of People in Australia’s Prisons 2022 (2023).

[2] Australian Institute of Health and Welfare, The Health of Australia’s Prisoners 2015 (2015).

[3] Ibid.

[4] Australian Bureau of Statistics, “Prisoners in Australia” (2024), https://www.abs.gov.au/statistics/people/crime-and-justice/prisoners-australia/latest-release.

[5] Ibid.

[6] Queensland Human Rights Commission, Stripped of Our Dignity: A Human Rights Review of Policies, Procedures, and Practices in Relation to Strip Searches of Women in Queensland Prisons (State of Queensland, 2023).

[7] Ibid., p. 28.

[8] Ibid.

[9] S. Kendall, S. Lighton, J. Sherwood, et al., “Incarcerated Aboriginal Women’s Experiences of Accessing Health Care and the Limitations of the ‘Equal Treatment’ Principle,” International Journal for Equity in Health 19/1 (2020); Australian Human Rights Commission, Human Rights and Prisoners, https://humanrights.gov.au/sites/default/files/content/letstalkaboutrights/downloads/HRA_prisioners.pdf.

[10] Kendall et al. (see note 9).

[11] Department of Health (Victoria), “Inquiry into Women’s Pain,” https://www.health.vic.gov.au/inquiry-into-womens-pain; Nurofen, “See My Pain,” https://www.nurofen.com.au/see-my-pain/.

[12] N. Gisev and R. Hopkins, “The TGA Is Considering Paracetamol Restrictions Due to Poisonings – But What Does That Mean for Consumers?,” The Conversation (September 29, 2022), https://theconversation.com/the-tga-is-considering-paracetamol-restrictions-due-to-poisonings-but-what-does-that-mean-for-consumers-191067.

[13] Therapeutic Goods Administration, “TGA Makes Final Decision to Reduce Paracetamol Pack Sizes,” (May 3, 2023), http://www.tga.gov.au/news/media-releases/tga-makes-final-decision-reduce-paracetamol-pack-sizes; Gisev and Hopkins (see note 12).

[14] National Health Service, A Review of Health and Social Care in Women’s Prisons (UK Government, November 23, 2023), https://www.england.nhs.uk/long-read/a-review-of-health-and-social-care-in-womens-prisons/.

[15] Australian Human Rights Commission (see note 9); Queensland Human Rights Commission (see note 6); A. Mackay, Towards Human Rights Compliance in Australian Prisons (ANU Press, 2020).

[16] Queensland Human Rights Commission (see note 6).

[17] International Penal Reform, Toolbox on the UN Bangkok Rules: UN Bangkok Rules on Women Offenders and Prisoners Short Guide (2013).

[18] Queensland, Human Rights Act 2019, sec. 37(1).

[19] PwC, Offender Health Services Review: Final Report (Queensland Department of Health, 2018), p. xiv.

[20] P. L. Simpson, J. Guthrie, J. Jones, et al., “Identifying Research Priorities to Improve the Health of Incarcerated Populations: Results of Citizens’ Juries in Australian Prisons,” Lancet Public Health 6/10 (2021); Australian Institute of Health and Welfare (2023, see note 1).

[21] L. A. Vandergrift and P. P. Christopher, “Do Prisoners Trust the Healthcare System?,” Health and Justice 9/15 (2021).

[22] S. Salebaigi, “Locked Up and Left Behind: Addressing Cruel and Unusual Punishments Among Senior Inmates During COVID-19 Across US Prisons,” Health and Human Rights 25/2 (2023).

[23] G. Niveau, “Relevance and Limits of the Principle of ‘Equivalence of Care’ in Prison Medicine,” Journal of Medical Ethics 33/10 (2007).

[24] J. Olds, R. Reilly, P. Yerrell, et al., “Exploring Barriers to and Enablers of Adequate Healthcare for Indigenous Australian Prisoners with Cancer: A Scoping Review Drawing on Evidence from Australia, Canada and the United States,” Health and Justice 6/1 (2016), p. 5; Vandergrift and Christopher (see note 21); E. Walsh, C. Butt, D. Freshwater, et al., “Managing Pain in Prisons: Staff Perspectives,” International Journal of Prisoner Health 10/3 (2014).

[25] S. P. Marks and A. L. Benedict, “Access to Medical Products, Vaccines and Medical Technologies,” in J. M. Zuniga, S. P. Marks, and L. O. Gostin (eds), Advancing the Human Right to Health (Oxford University Press, 2013); N. E. Morone and D. K Weiner, “Pain as the Fifth Vital Sign: Exposing the Vital Need for Pain Education,” Clinical Therapeutics 35/11 (2013).

[26] Walsh et al. (see note 24).

[27] Australian Institute of Health and Welfare, The Health of Australia’s Males (2023), https://www.aihw.gov.au/reports/men-women/male-health/contents/access-health-care.

[28] Walsh et al. (see note 24).

[29] K. J. Templeton, “Sex and Gender Issues in Pain Management,” Journal of Bone and Joint Surgery 102/Suppl 1 (2020); E. J. Bartley and S. Palit, “Gender and Pain,” Current Anesthesiology Reports (Philadelphia) 6/4 (2016); C. Moretti, E. De Luca, C. D’Apice, et al., “Gender and Sex Bias in Prevention and Clinical Treatment of Women’s Chronic Pain: Hypotheses of a Curriculum Development,” Frontiers in Medicine (Lausanne) 10/1189126 (2023); L. Zhang, E. A. Reynold Losin, Y. Ashar, et al., “Gender Biases in Estimation of Others’ Pain,” Journal of Pain 22/9 (2021); G. Schäfer, K. M. Prkachin, K. A. Kaseweter, and A. C. de C. Williams, “Health Care Providers’ Judgments in Chronic Pain: The Influence of Gender and Trustworthiness,” Pain 157/8 (2016).

[30] Templeton (see note 29), p. 32.

[31] Zhang et al. (see note 29).

[32] Bartley and Palit (see note 29).

[33] K. Hoffman, J. Trawalter, and M. Oliver, “Racial Bias in Pain Assessment and Treatment Recommendations, and False Beliefs About Biological Differences Between Blacks and Whites,” Proceedings of the National Academy of Sciences 113/16 (2016); Moretti et al. (see note 29), p. 2.

[34] S. G. Gabel, “Understanding a Rights-Based Approach to Social Policy Analysis,” in S. G. Gabel (ed), A Rights-Based Approach to Social Policy Analysis (Springer, 2016), p. 5.

[35] National Health Service (see note 14).

[36] Council of Europe, Gender Mainstreaming Toolkit for Co-operation Projects (2018).

[37] V. Braun and V. Clarke, Thematic Analysis: A Practical Guide to Understanding and Doing (Sage, 2021).

[38] P. Scraton, “Bearing Witness to the ‘Pain of Others’: Researching Power, Violence and Resistance in a Women’s Prison,” International Journal for Crime, Justice and Social Democracy 5/1 (2016).

[39] Ibid.; C. Bacchi, “Gender/ing Impact Assessment: Can It Be Made to Work?,” in C. Bacchi and J. Eveline (eds), Mainstreaming Politics: Gendering Practices and Feminist Theory (University of Adelaide Press, 2010); M. M. T. Verloo, “Mainstreaming Gender Equality in Europe: A Critical Frame Analysis Approach,” Επιθεώρηση Κοινωνικών Ερευνών 117 (2005).

[40] European Institute for Gender Equality, Gender Impact Assessment: Gender Mainstreaming Toolkit (Publications Office of the European Union, 2017).

[41] A. Shepherd, T. Hewson, J. Hard, et al., “Equivalence, Justice, Injustice: Health and Social Care Decision Making in Relation to Prison Populations,” Frontiers in Sociology 2021/6 (2021).

[42] Her Majesty’s Inspectorate of Prisons, Expectations: Criteria for Assessing the Treatment of and Conditions for Women in Prison (UK Government, 2014).

[43] Australian Institute of Health and Welfare (2023, see note 1).

[44] Bartley and Palit (see note 29).

[45] Vandergrift and Christopher (see note 21); Walsh et al. (see note 24).

[46] Walsh et al. (see note 24).

[47] L. Yap, T. Butler, J. Richters, et al., “Do Condoms Cause Rape and Mayhem? The Long-Term Effects of Condoms in New South Wales’ Prisons,” Sexually Transmitted Infections 83/3 (2007); Queensland Human Rights Commission (see note 6).

[48] Scraton (see note 38).

[49] Olds et al. (see note 24).

[50] Y. I. Hwang, N. Ginnivan, P. Simpson, et al., “COVID-19 and Incarcerated Older Adults: A Commentary on Risk, Care and Early Release in Australia,” International Journal of Prisoner Health 17/3 (2021); J. Amon, “COVID-19 and Detention,” Health and Human Rights 22/1 (2020).

[51] Niveau (see note 23).

[52] Schäfer et al. (see note 29).

[53] S. Melander, “Different Logics of Pain: The Gendered Dimension of Chronic Pain in a Relational Setting,” Social Science and Medicine 335/116229 (2023).

[54] Niveau (see note 23); F. Jotterand and T. Wangmo, “The Principle of Equivalence Reconsidered: Assessing the Relevance of the Principle of Equivalence in Prison Medicine,” American Journal of Bioethics 14/7 (2014); T. N. A. Winkelman, K. C. Dasrath, J. T. Young, et al., “Universal Health Coverage and Incarceration,” Lancet Public Health 7/6 (2022).

[55] Kendall et al. (see note 9).

[56] Amon (see note 50).