Eating disorders in prisons: improving identification, care and research

Eating disorders among people in prison remain under-recognised, under-researched and difficult to address within custodial health systems.

In the September National Scientific Seminar Series, Laurie Hopkins, NSW Eating Disorders Coordinator and Clinical Nurse Consultant at NSW Justice Health and Forensic Mental Health Network, discussed eating disorder presentations among adults in custody. Drawing on their clinical and service development experience, Laurie explored the challenges of assessment, treatment and healthcare delivery in prison settings, as well as priorities for future research.

Culturally safe healthcare in custodial settings

Laurie began by emphasising that people in prison are in the care of the state and deserve access to high-quality healthcare.

They also highlighted the importance of culturally safe healthcare for Aboriginal people, who are significantly overrepresented in NSW prisons. Laurie noted that approximately 30% of people in NSW prisons are Aboriginal and stressed that cultural safety must be embedded at a systems level, rather than treated as an additional consideration for individual patients. A strong Aboriginal health lens can contribute to safer and more responsive healthcare for everyone in custody.

How can prison environments affect eating disorders?

People entering custody may experience multiple and overlapping health concerns, including trauma, mental health conditions, neurodivergence, cognitive disability and substance use. The prison environment can introduce further challenges, including:

• highly regulated access to food, healthcare and exercise
• frequent movement between correctional centres and healthcare teams
• limited privacy during clinical appointments
• long periods of confinement
• disrupted continuity of care
• limited access to preferred or sensory-safe foods.

Laurie explained that food and exercise can become some of the few areas in which people feel they retain a sense of control. For people with an existing eating disorder, these conditions may contribute to symptoms returning or becoming more severe. Laurie’s clinical experience also suggests that some people may develop eating disorder symptoms after entering custody.

Food access and disordered eating in prison

Prison meal schedules, limited food choices and the way food is distributed can create additional challenges and complicate people’s relationships with food. In the settings Laurie described, much of a person’s daily food may be provided at once, while access to additional purchased food, known as “buy-up”, generally occurs once a week. Laurie observed that this pattern can contribute to cycles of binge eating, restriction and compensatory exercise.

The environment can be particularly challenging for autistic people and those with avoidant/restrictive food intake disorder (ARFID) presentations. Laurie described instances in which people who had managed adequately in the community could no longer access enough familiar or sensory-safe foods in custody, leading to inadequate nutrition and medical concerns.

Exercise, muscularity and physical safety

Exercise is common within prison environments and may serve several functions. Laurie explained that people may exercise to manage distress, cope with confinement, build a sense of physical safety or change how others perceive them.

This can make compulsive exercise difficult to identify. Muscularity-oriented eating and exercise may be connected not only to body image, but also to trauma, perceived toughness and protection. Laurie also discussed muscle dysmorphia and the use of performance and image-enhancing drugs as important areas requiring greater recognition.

Why can eating disorders be difficult to identify?

Eating disorders can be difficult to detect in custody. People may not disclose their symptoms, particularly in an environment where keeping a low profile can feel important for personal safety reasons. Their community health information may also be incomplete or unavailable.

Symptoms can be further obscured by more immediately visible concerns, such as psychosis, substance use, self-harm, personality-related difficulties or acute physical illness. Laurie noted that eating disorders may also be overlooked in men and in people whose bodies or symptoms do not fit common assumptions about who experiences an eating disorder.

There are currently no eating disorder screening tools validated specifically for custodial populations. Rather than adding a single question to an already lengthy reception assessment, Laurie has focused on building workforce knowledge and clinical competence. They reported that referrals increased following education sessions with clinicians, particularly at correctional centres where staff were strongly engaged.

Adapting eating disorder care to custodial environments

Delivering standard eating disorder treatments can be difficult in prisons. Frequent transfers, operational restrictions, limited resources and interruptions to clinical access can make it challenging to provide a consistent course of therapy.

Laurie described an approach that integrates eating disorder care into existing health and psychological services. Its practical foundations include:

• supporting people to eat regularly and adequately
• providing clear psychoeducation
• helping people develop alternative coping skills
• building a therapeutic relationship
• exploring the factors contributing to eating disorder symptoms.

Laurie stressed that this approach is evidence-informed rather than established as a validated treatment model for custodial populations. However, their clinical experience indicates that brief interventions and improved understanding can potentially lead to meaningful change.

Correctional officers may also support early identification because they regularly observe people’s eating and exercise behaviours. Laurie described some officers as important allies while acknowledging the need for appropriate training so that responses to eating disorder symptoms do not unintentionally cause further harm.

Building the evidence for eating disorder care in prisons

A current NSW research project aims to address some of the substantial evidence gaps in this area. The study is using patient tablets in correctional centres to administer a disordered eating screening measure. A selection of participants with positive and negative screening results will then complete further diagnostic and clinical assessments.

The research aims to assess the screening measure’s suitability for custodial populations and produce an estimate of eating disorder prevalence risk. It will also collect information about co-occurring experiences and conditions, including adverse childhood experiences and other mental health concerns.

Future priorities identified by Laurie include:

• establishing how common eating disorders are among people in prison
• validating screening and assessment tools for custodial populations
• identifying effective and practical treatment approaches
• improving continuity of care across correctional centres and community services
• strengthening workforce education
• conducting similar research in youth justice settings.

Eating disorders do not disappear when someone enters custody. Improving identification and care will require culturally safe and responsive systems, stronger evidence, an informed workforce and eating disorder care embedded within everyday custodial health practice.