563271

research-article2014
TPJXXX10.1177/0032885514563271The Prison JournalCarcedo et al.

Article
The Prison Journal
2015, Vol. 95(1) 4365
The Relationship 2014 SAGE Publications
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DOI: 10.1177/0032885514563271
Satisfaction and tpj.sagepub.com

Psychological Health
of Prison Inmates: The
Moderating Effects of
Sexual Abstinence and
Gender

Rodrigo J. Carcedo1, Daniel Perlman2,

Flix Lpez1, M. Begoa Orgaz1,
and Noelia Fernndez-Rouco1,3

Abstract
Research has found a relationship between sexual satisfaction and
psychological health in prisoners, although few studies have focused on
possible moderators of this relationship. The main foci of this study of
a sample of prison inmates were as follows: (a) the association between
sexual satisfaction and psychological health and (b) the moderating effects
of heterosexual activity level (abstinent vs. non-abstinent) and gender on
the relationship between these two variables. In-person interviews were
conducted with 82 males and 91 females who lived in separate modules in
Spains Topas Penitentiary. Sexual satisfaction was a significant predictor of
psychological health only for members of the sexually abstinent group. These

1University of Salamanca, Salamanca, Spain

2University of North Carolina, Greensboro, NC, USA
3University of Cantabria, Santander, Spain

Corresponding Author:
Rodrigo J. Carcedo, Department of Developmental and Educational Psychology, University of
Salamanca, Facultad de Psicologa, Avda. de la Merced, 109-131 37005 Salamanca, Spain.
Email: rcarcedo@usal.es

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44 The Prison Journal 95(1)

findings point to the positive effect of sexual satisfaction on psychological

health, especially for the inmates in a less favorable sexual situation (i.e.,
sexual abstinence).

Keywords
sexual abstinence, sexual satisfaction, psychological health, prison inmates

The research to be reported in this article focused on (a) the differences in

sexual satisfaction as a function of gender and the level of sexual activity
(being sexually abstinent or not), (b) the relationship between sexual satis-
faction and psychological health, and (c) the moderating effect of gender
and level of sexual activity on this relationship. Many authors have noted
that inmates suffer due to heterosexual sexual relationship deprivation in
prison (Lacombe, 1997; Levenson, 1983; Maeve, 1999; Neuman, 1982;
Snchez, 1995). However, none of the authors has empirically tested
whether these inmates showed less sexual satisfaction than the inmates
who have had sex. The role of gender in this relationship is also unknown.
In addition, some prison studies have found a relationship between sexual
satisfaction and psychological health (Carcedo, Lpez, Orgaz, Toth, &
Fernndez-Rouco, 2008), but there are no studies of whether this associa-
tion is moderated by other variables such as gender and the level of sexual
activity.

Gender, Sexual Abstinence, and Sexual Satisfaction

Female inmates have been found to show higher levels of sexual satisfaction
than males (Carcedo et al., 2008). However, after controlling for age, nation-
ality, total time in prison, actual sentence time served, and estimated time to
parole and partner status, this difference was not statistically significant
(Carcedo et al., 2011).
Several authors have reported negative feelings toward abstinence by both
male and female inmates (i.e., Lacombe, 1997; Maeve, 1999; Neuman, 1982;
Snchez, 1995). However, only one study of prison inmates has empirically
investigated the differences in the sexual satisfaction of heterosexually absti-
nent and heterosexually active inmates, finding much lower levels of sexual
satisfaction in the sexually abstinent group (Carcedo, 2005). Gender was not
taken into account in that study, although this is an important variable to con-
sider. In the present study, sexual abstinence and gender effects will be exam-
ined together with respect to inmates sexual satisfaction.

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Carcedo et al. 45

Sexual Satisfaction and Psychological Health

Prison inmates have been identified as an at-risk population for poor psycho-
logical health because of the distress associated with incarceration (Toch,
1977; Zamble & Porporino, 1988). One of the possible causes of this risk is
that inmates encounter difficulties in having a satisfactory sex life (Carcedo,
2005; Lacombe, 1997; Levenson, 1983; Maeve, 1999; Neuman, 1982).
Linville (1981) found that approximately three quarters of a sample of 100
males in a minimum-security prison reported emotional problems because of
sexual deprivation. In addition, sexual satisfaction and psychological health
and other well-being-related measures have been shown to be significantly
related in prison settings (Carcedo, 2005; Carcedo et al., 2008; Carcedo,
Perlman, Lpez, & Orgaz, 2012) and non-prison studies (Fegg et al., 2003;
Lau, Wang, Cheng, & Yang, 2005; Nicolosi, Moreira, Villa, & Glasser, 2004;
Taleporos & McCabe, 2002). Higher levels of sexual satisfaction were asso-
ciated with higher levels of psychological health and other well-being related
measures.

Moderating Effect of Gender and Sexual

Abstinence on the Relationship Between Sexual
Satisfaction and Psychological Health
The suffering and the deterioration of psychological health due to the lack
of sexual satisfaction have been suggested regarding male inmates
(Lacombe, 1997; Levenson, 1983; Linville, 1981; Neuman, 1982), female
inmates (Pardue, Arrigo, & Murphy, 2011; Snchez, 1995), and both gen-
ders (Carcedo et al., 2008; Carcedo et al., 2012). However, it is unknown if
the relationship between sexual satisfaction and psychological health is dif-
ferent for male and female inmates. In a study of 118 male and 70 female
prison inmates, Carcedo et al. (2008) found that sexual satisfaction signifi-
cantly explained the psychological health for both genders, although 6.2%
more of the variance was explained for females than males. Notwithstanding,
the possible moderator effect of gender was not tested. In non-prison popu-
lation studies that have strictly measured sexual satisfaction or sexual well-
being, this variable has been associated with psychological health and
happiness in both genders, but the relationship between sexual variables
and psychological measures has been slightly stronger among women than
among men (Laumann et al., 2006; Taleporos & McCabe, 2002). Thus, the
possibility that gender moderates the relationship between sexual satisfac-
tion and psychological health warrants consideration. This will also be
examined in the present study.

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46 The Prison Journal 95(1)

In arguing that a lack of sexual satisfaction can negatively impact prison

inmates psychological health, most authors (Lacombe, 1997; Levenson,
1983; Maeve, 1999; Neuman, 1982; Snchez, 1995) were referring mainly to
inmates who have not had heterosexual sexual relationships during their
incarceration. Thus, these authors were implicitly confounding sexual satis-
faction with sexual abstinence. Whereas sexual satisfaction reflects an evalu-
ation of ones current sexual life, sexual abstinence refers to the complete
lack of sexual relationships during a period of time. These different concepts
may delineate different situations: An inmate may have been sexually absti-
nent during the last 6 months, yet show reasonable high sexual satisfaction.
By contrast, an inmate may have been sexually active, yet have low sexual
satisfaction. In addition, the relationship between inmates sexual satisfaction
and psychological health may be different for sexual abstainers versus sexu-
ally active individuals. No prison study has investigated this moderating
effect. Notwithstanding, non-prison studies have found a stronger relation-
ship between sexual satisfaction and general well-being for those who have
been sexually deprived due to the presence of sexual dysfunctions (Lau et al.,
2005; Ventegodt, 1998), physical disabilities (Taleporos & McCabe, 2002),
amputations (Walters & Williamson, 1998), and having had germ-cell tumor
therapy (Fegg et al., 2003). Therefore, the moderating effect of being sexu-
ally abstinent versus active in the relationship between sexual satisfaction
and psychological health will be tested in this research.
According to reactance theory (RT; Brehm, 1966), any form of depriva-
tion may increase the desire for the deprived object (Brehm & Brehm, 1981),
amplifying its relevance for individuals psychological health. The major
premise of RT is that individuals wish to operate with a freedom to choose
behaviors to satisfy their needsin this case sexual needs. If their freedom is
reduced, threatened, or eliminated, individuals will become motivationally
aroused to regain this freedom (Brehm, 1966, p. 2). Thus, psychological
reactance is a motivational state directed toward the re-establishment of free
behaviors that have been eliminated or threatened with elimination. (p. 9).
With reference to this research, reactance is likely to be high among inmates
whose access to heterosexual activity is thwarted by their circumstances. We
believe that in enhancing the value of sex, such reactance may intensify the
association between their sexual satisfaction and psychological well-being.

Control Variables
Other variables have been demonstrated to be related to inmates psychologi-
cal health. For example, a set of socio-demographic and punishment-related
variables have been found to be important. Poorer mental health has been

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Carcedo et al. 47

exhibited by inmates who are younger, Caucasian (Lindquist, 2000), married

(Lindquist, 2000; Lindquist & Lindquist, 1997), and who have longer sen-
tences and a longer expected time prior to their release (James & Glaze,
2006). Due to these findings, the authors include age, ethnic group-nationality,
partner status, total time in prison, actual sentence time served, and estimated
time to parole as control variables when predicting psychological health.
Although the relationship between these variables and sexual satisfaction has
not been investigated in prison research, these variables were also included in
analyzing the effect of sexual abstinence on sexual satisfaction because of
their potential association with inmates sexual satisfaction.
In addition, masturbation has been found to be related to sexual satisfac-
tion and well-being-related measures in non-prison studies (Das, 2007; Das,
Parish, & Laumann, 2009; Langstrom & Hanson, 2006), and social loneli-
ness has been shown to be an important predictor of prisoners psychological
health (Carcedo et al., 2008). Taking these results into consideration, we also
included the frequency of masturbation as a possible predictor of sexual sat-
isfaction and psychological health, and social loneliness as a possible predic-
tor of psychological health.
In sum, we set out to examine the following research questions in this
study: (a) Will gender and sexual abstinence be associated with inmates
sexual satisfaction after controlling for age, ethnic group-nationality, part-
ner status, total time in prison, actual sentence time served, estimated time
to parole, and frequency of masturbation? (b) Will sexual satisfaction be
associated with inmates psychological health after controlling for age, eth-
nic group-nationality, partner status, total time in prison, actual sentence
time served, estimated time to parole, social loneliness, and frequency of
masturbation? (c) Will gender and/or sexual abstinence play a moderating
role in the relationship between sexual satisfaction and psychological
health? More specifically, will sexual satisfaction explain more variance in
the psychological health among inmates in the worse-off heterosexually
abstinent group than among inmates in the heterosexually active group?
Will sexual satisfaction explain more variance in the psychological health
of females than of males?

Method
Design
The data for this study were collected in two sessions. The primary variables
of our study were all evaluated in the first session. These included sexual
satisfaction (the main predictor variable), social loneliness and frequency of

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48 The Prison Journal 95(1)

masturbation (other relevant interpersonal and sexual predictors), the moder-

ating variables (heterosexual activity level and gender), and the control vari-
ables (age, nationality, partner status, total time in prison, actual sentence
time served, and anticipated time to parole). The outcome variable (psycho-
logical health) was evaluated in the second session. Depending on the
inmates schedules, the second session was conducted approximately a week
later. The heterosexual activity status of participants (i.e., abstinent vs. het-
erosexually active) was obtained in both sessions. It was checked in the sec-
ond session to verify that the situation of the inmates had not changed between
sessions. There was no participant change.

Participants
In total, 173 medium-security prison inmates (91 men and 82 women) from a
prison in the northwestern region of Spain provided data for this study during
2008. Their average age was 35.10 years, with a range from 20 to 62.
Regarding nationality, 41.04% (n = 71) were Spanish, whereas 58.96% were
foreigners (n = 102). While 35.26% (n = 61) had no romantic partner, 64.74%
(n = 112) had a partner. The mean of total time in prison for all offenses,
actual sentence time served for their current offense, and estimated time to
parole were 51.35, 42.61, and 24.98 months, respectively.
With respect to the characteristics of the sample regarding sexual behav-
ior, 46.24% (n = 80; 53 men and 27 women) of the inmates had been sexually
abstinent for at least 6 months, and 53.76% (n = 93; 29 men and 64 women)
had had sexual relationships in the last 6 months. Inmates reported that all
their sexual relationships had been heterosexual and had included vaginal
coitus at least once in the last 6 months. All these sexual behaviors were con-
sensual except for the case of one female and one male inmate who had also
had consensual sexual relationships. Finally, of the heterosexually active
group, 6.59% reported having maintained sexual relationships during their
furloughs outside the prison, 74.72% reported having had sexual relation-
ships in the conjugal visits rooms inside the prison, and 24.18% reported
having had sexual relationships in other areas inside the prison where men
and women share different activities (e.g., at their workplace in prison, the
socio-cultural module, the gym, etc.). Although some of the inmates reported
having had homosexual contacts in prison, none reported having had homo-
sexual contacts during the 6 months prior to data collection.
Participants were selected to have an equal number of men and women.
After stratifying by gender, 80% of the participants were randomly selected,
while 20% were selected under a snowball sampling scheme (Goodman,
1961). Participants were excluded under the following conditions: (a) they

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Carcedo et al. 49

had been in prison for less than 6 months, the time considered necessary to
adapt to prison life and develop new relationships inside the facility; (b) the
estimated time to parole was less than a month, a period when inmates are
usually focused on being released more than their life in prison; (c) they did
not speak Spanish or English; (d) they had been diagnosed with a serious
mental disorder (e.g., psychotic and mood disorders); or (e) they were not in
optimal condition to be interviewed (e.g., under the influence of drugs or
expressing high levels of anxiety or distrust toward the interviewer). Only
eight potential participants declined or stated that they were not interested in
being interviewed. Due to an interviewer error or that the inmate refused to
answer, 23 participants skipped a single item from one or more scales, but
they were included in the analyses using the mean of the other items in the
scale that had been answered. All of the participants considered the interview
as a generally positive experience, especially because it gave them an oppor-
tunity to express their personal worries and feelings.

Procedure
This study is part of a larger project that involved two interview sessions. The
first author conducted in-person interviews with each participant in a private
room, separated from the rest of the inmates, in the inmates module. Both
sessions consisted of interview questions formulated specifically for this
project and standardized questionnaires. Both kinds of measures were mixed
in the two sessions. The time needed to complete questionnaires was kept
short (approximately 30 min) to avoid participants either getting tired or
experiencing an invasive sense of being questioned (i.e., an interrogation
effect).
The first session lasted between 60 and 90 min. Before the start of the
interview, the interviewer spent a significant amount of time gaining each
inmates trust. Usually, the trust-building phase took around 20 min.
However, depending on the inmates responsiveness, in some cases it took
up to 2 hr. Before beginning the interview itself, participants were invited
to read and sign the consent form. They also were asked to participate and
were informed about the possibility of leaving the study whenever they
wished to do so. In addition, participants were informed about the confiden-
tiality and anonymity of their answers, which meant that any information
given during the interview would not be divulged and their names would
not appear in any printed reports. No names were attached to the interviews
and an informed consent statement was signed by the inmate and the inter-
viewer. Approximately a week later, the second session was conducted; it
usually lasted around 30 min.

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50 The Prison Journal 95(1)

Measures
Primary predictor variable: Sexual satisfaction. To measure this construct, the
Sexual Satisfaction subscale of the Multidimensional Sexual Self-Concept
Questionnaire (MSSCQ; Snell, 1995) was used. A total of five items were
scored on 5-point Likert-type scales that ranged from 1 (not at all character-
istic of me) to 5 (very characteristic of me). The total sexual satisfaction score
was obtained by summing the scored items and dividing them by the number
of items answered. Possible scores range from 1 to 5 (high sexual satisfac-
tion). Coefficient alpha for this subscale was .96.

Other interpersonal and sexual predictor variables: Social loneliness and frequency
of masturbation. To measure loneliness, the five-item social loneliness sub-
scale of the short version of the Social and Emotional Loneliness Scale for
Adults (SELSA-S; DiTommaso, Brannen, & Best, 2004) was used. Items
were answered on a 7-point Likert-type scale that ranged from 1 (strongly
disagree) to 7 (strongly agree). The total score was obtained by adding the
individual scores and dividing them by the number of items answered. Pos-
sible scores range from 1 to 7 (high loneliness). Coefficient alpha for this
subscale was .81.
The following question was used to measure masturbation: Masturbation
is a normal and very common human behavior. In the last 6 months, how
often did you masturbate? The possible answers ranged from 1 (never), 2
(less than once per month), 3 (once or twice per month), 4 (once or twice per
week), 5 (once per day), to 6 (more than once per day).

Moderating variables: Heterosexual activity level (abstinence) and gender.Absti-

nence was recorded as 0 for the inmates who had not experienced any sexual
relationships in the past 6 months, and 1 for the inmates who had had at least
one sexual relationship in the last 6 months. Gender was recorded as 0 for
females and 1 for males.

Outcome variable: Psychological health. To assess this dimension, the short,

Spanish version of the Psychological Health subscale of the World Health
Quality of Life scale (WHOQOL-BREF; Lucas, 1998) was used. Six
items were scored on a 5-point Likert-type scale that ranged, with differ-
ent labels, from 1 (not at all; very dissatisfied; never) to 5 (extremely-completely;
very satisfied; always). The Psychological Health State score was obtained
by summing the individual scores and dividing them by the number of
items answered. Possible score range from 1 to 5 (positive health). Alpha
was .72.

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Carcedo et al. 51

Control variables
Age. Inmates were asked to state their ages, and this variable was con-
firmed using inmate penitentiary records to ensure accuracy.

Partner status. This item was rated as 0 for inmates without a partner and
1 for inmates in a romantic relationship.

Nationality. Nationality was split into Spaniards (0) versus foreigners (1).

Total time in prison. This variable was obtained from the sum of all time
spent in a prison for previous and current offenses. It was collected by review-
ing inmates penitentiary records and recorded in months.

Actual sentence time served.This item denotes the time spent in prison
since the last entry (i.e., during the current prison term). It also was obtained
from inmate penitentiary records and listed in months.

Estimated time to parole.After discussions with the legal advisors from

Topas Penitentiary, we chose to take three quarters of participants actual
sentences as the expected time when inmates would be paroled due to the
fact that it was the modal parole time. This fact was familiar to the inmates,
thus they were likely to expect parole around this time. Clearly, actual time to
parole varies, depending on inmates characteristics and behavior. The esti-
mated time to parole was the amount of time remaining before each inmates
expected parole date. This variable was also recorded in months.

Analysis Strategy
The primary research issue addressed by this project is how the sexual satis-
faction of heterosexually abstinent (male and female) and heterosexually
active (male and female) inmates is related to their psychological health.
Because of the presence of non-orthogonality in the design (i.e., sexual activ-
ity level is significantly associated with gender, see Table 1), the individual
and combined effects of sexual activity level, gender, and sexual satisfaction
on psychological health were assessed. In particular, we used the model com-
parisons strategy recommended by Neter, Kutner, Nachtsheim, and
Wasserman (1996) who applied previous authors recommendations on
ANOVA designs (Appelbaum & Cramer, 1974; Cramer & Appelbaum, 1980;
Maxwell & Delaney, 1990) to regression designs. Following Neter et al.s
recommendations, a logical sequence of model comparisons is undertaken,
beginning with the test of the higher order interaction (third order: Sexual

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52 The Prison Journal 95(1)

Table 1. Descriptive Statistics of Major Variables for Sexual-Abstinent and Non-

Sexual-Abstinent Groups.

Sexually abstinent Sexually active

(n = 80) (n = 93)

M (SD) M (SD)

Variables % % p
1. Age 35.44 (8.37) 34.81 (7.18)
2. Nationality (Spanish) 39.44% 60.56%
3. Partner status (with partner) 24.11% 75.89% ***
4. Total time in prison 58.78 (57.08) 44.96 (33.06)
5. Actual sentence served 44.06 (47.25) 41.35 (32.05)
6. Time to parole 25.68 (21.51) 24.37 (16.24)
7. Social loneliness 3.84 (1.80) 3.03 (1.60) **
8. Frequency of masturbation 2.86 (1.42) 2.69 (1.40)
9. Gender (males) 64.63% 35.37% ***
10. Sexual satisfaction 1.44 (0.78) 3.38 (1.34) ***
11. Psychological health 3.32 (0.78) 3.65 (0.67) **

Note. Chi-squares were performed using the exact test. Asymptotic likelihood ratio chi-
squares yielded the same significant differences.
*p < .05. **p < .01. ***p < .001.

satisfaction Sexual activity level Gender), proceeding to a test of lower

order interactions (second order: Sexual satisfaction Sexual activity level,
Sexual satisfaction Gender, and Sexual activity level Gender) in the pres-
ence of the others (eliminating tests), and finally a test of each interaction in
the absence of the other (ignoring tests). At the end of this procedure, the
so-called conditional effects are tested. These effects are also called main
effects in ANOVA designs (see Hayes & Matthes, 2009). Akin to the proce-
dure used with second-order interactions, at this stage, a test of each main
effect in the presence of the other main effects is performed (eliminating
tests), and, finally, a test of each main effect in the absence of the other main
effects (ignoring tests) is performed. Only the minimum number of tests nec-
essary to logically determine a final statistical model is performed, allowing
valid conclusions to be drawn even in the presence of highly non-orthogonal
regression models (Neter et al., 1996).
In all the analyses reported here, participant age, partner status, national-
ity, total time in prison, actual sentence time served, estimated time to parole,
social loneliness, and frequency of masturbation were controlled because

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Carcedo et al. 53

previous research has linked them to prisoner and non-prison psychological

health (Carcedo et al., 2008; Das, 2007; Das et al., 2009; James & Glaze,
2006; Langstrom & Hanson, 2006; Lindquist, 2000; Lindquist & Lindquist,
1997). Also, participant age, total time in prison, actual sentence time served,
estimated time to parole, social loneliness, frequency of masturbation, and
sexual satisfaction were centered before entry into the models. Thus, the
parameter estimates associated with sexual satisfaction, gender, and sexual-
abstinent group are referenced to an average Spaniard prison inmate with-
out a partner (i.e., one of an average age of 35 years, who has served an
average 51 months of total time in prison, who has been incarcerated for an
average 42 months during the current stay, and who has an average esti-
mated 25 months remaining until parole).
As shown in Table 1, heterosexually abstinent and heterosexually active
inmates are differently distributed within gender categories. Under these cir-
cumstances, asymptotic likelihood ratio tests of categorical association are
likely to be inaccurate. Thus, all tests of categorical association were con-
ducted under a permutation-based exact test statistical modeling framework
(Mehta & Patel, 2002, pp. 9-39), yielding p values and conclusions that
remain valid under the conditions observed.
To study how sexual abstinence and gender were related to sexual satisfac-
tion, the same analytic approach was utilized. In this case, the logical
sequence of model comparisons starts with the test of interaction (Sexual
activity level Gender), proceeding to a test of each main effect in the pres-
ence of the other (eliminating tests), and finally a test of each main effect in
the absence of the other (ignoring tests).
SPSS 17.0 was used for data analysis. This program and the MODPROBE
script (Version 1.2) developed by Hayes and Matthes (2009) were used for
probing and plotting the interactions. The pick-a-point approach (Aiken &
West, 1991; Cohen, Cohen, West, & Aiken, 2003) was utilized. This proce-
dure selects representative values of the moderator variable (in this case, two
categories: 0 for sexual-abstinent, and 1 for non-sexual-abstinent) and
then estimates the effect of the focal predictor at those values.

Results
Descriptive statistics were calculated and are displayed in Table 1 separately
by heterosexually abstinent and heterosexually active inmates. To examine
whether there are mean differences based on sexual activity status for the
study variables, t tests for independent samples and chi-square tests (exact
test) were conducted.

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54 The Prison Journal 95(1)

Sexual Activity and Gender Differences on Sexual Satisfaction

An ANCOVA was performed to analyze the main and interaction effects of
sexual activity and gender on sexual satisfaction after controlling for age,
nationality, partner status, total time in prison, actual sentence time served,
and estimated time to parole. In short, neither gender nor the control variables
were significantly associated with sexual satisfaction. Nor were any signifi-
cant interaction effects between gender and level of sexual activity found for
sexual satisfaction. Sexual activity level, however, was significantly associ-
ated with sexual satisfaction (B = 1.805, SE = .228, R2 = .457, p < .001).
After accounting for the control variables, Bonferroni post hoc comparisons
were used to analyze the differences between the heterosexually abstinent
and heterosexually active groups, using estimated marginal means, also
called least-squares means. As was expected, the heterosexually abstinent
inmates (M = 1.511, SE = .148) reported much lower levels of sexual satisfac-
tion than the heterosexually active ones (M = 3.316, SE = .136).

Moderating Effect of Sexual Activity and Gender on the

Relationship Between Sexual Satisfaction and Psychological
Health
Regarding the interaction effect of Sexual satisfaction Heterosexual activity
level and Sexual satisfaction Gender on psychological health, a series of hier-
archical linear regression analyses were performed. The Type III Sums of Squares
and a simultaneous entry of the variables in different steps were utilized. We used
the analysis strategy described above (Neter et al., 1996). Socio-demographic
and penitentiary control variables (age, nationality, total time in prison, actual
sentence time served, and time to parole) were included in the first step; interper-
sonal and sexual variables (social loneliness and frequency of masturbation) were
included in the second step; conditional effects of sexual satisfaction, heterosex-
ual activity level, and gender were added in the third step; the three 2-way inter-
actions (Sexual satisfaction Heterosexual activity level, Sexual satisfaction
Gender, and Heterosexual activity level Gender) were added in the fourth step;
and the 3-way interaction (Sexual satisfaction Heterosexual activity level
Gender) was included in the fifth step. The third-order level interaction was not
significant. Then, this interaction was dropped from the final model, and we con-
tinued studying the model with the three second-order possible interactions.
Table 2 builds different sequences of hierarchical regression analyses,
once the three-way interaction was dropped. Model 1 only includes the con-
trol variables. Model 2 adds interpersonal and sexual variables. Model 3 adds
the conditional effects and interactions of the variables on which this study is

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Carcedo et al. 55

Table 2. Predictors of the Prison Inmates Psychological Health.

Psychological health

Model 1 Model 2 Model 3 Model 4

B SE B SE B SE B SE

Step 1: Control variables (socio-demographics and penitentiary)

Age 0.003 0.007 0.003 0.007 0.000 0.006
Nationality 0.399*** 0.116 0.440*** 0.107 0.487*** 0.103 0.422*** 0.096
Partner status 0.167 0.117 0.054 0.110 0.179 0.128
Total time in prison 0.000 0.002 0.001 0.002 0.000 0.002
Actual sentence served 0.002 0.003 0.002 0.002 0.002 0.002
Time to parole 0.009** 0.003 0.007* 0.030 0.006* 0.003 0.004 0.002
Step 2: Interpersonal and sexual variables
Social loneliness 0.170*** 0.030 0.158*** 0.029 0.150*** 0.028
Frequency of masturbation 0.023 0.037 0.007 0.039
Step 3: Conditional effects
Gender 0.040 0.204
Sexual activity level 0.499 0.267 0.468* 0.231
Sexual satisfaction 0.360*** 0.102 0.351*** 0.089
Step 4: Interaction model
Gender Sexual activity level 0.205 0.265
Gender Sexual satisfaction 0.014 0.086
Sexual satisfaction Sexual 0.261* 0.103 0.266** 0.101
activity level
R2 .126 .269 .360 .344

Note. The same interaction effect was found when selected only the participants who did not miss any item
from the scales (n = 150).
*p < .05. **p < .01. ***p < .001.

focused. Finally, Model 4 includes only the variables and the interaction that
proved to be significant in Model 3. In this last model, the parameters of
nationality, social loneliness, sexual satisfaction, heterosexual activity level
(in this case because it is necessary for the interaction term), and the interac-
tion between sexual satisfaction and heterosexual activity level were esti-
mated. In Model 1, only nationality and estimated time to parole showed to
be significant. In Model 2, the significant variables that entered in the model
were nationality, estimated time to parole, and social loneliness. Models 3
and 4 showed that nationality, estimated time to parole (not in Model 4),
social loneliness, sexual satisfaction, and the interaction between sexual sat-
isfaction and heterosexual activity level were significant. The contribution of
explained variance by the interaction term to the Model 4 was significant
(R2 = .027, p = .009). Being a foreign inmate, being lower in social loneliness,
having a shorter estimated time to parole, and being higher in sexual satisfac-
tion were associated with higher psychological health (see Table 2).

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56 The Prison Journal 95(1)

Table 3. Conditional Effects of Sexual Satisfaction at Two Sexual Activity Levels

on Psychological Health.

Psychological health

B SE t 95% CI
Sexual activity level
Sexual-abstinent (0) 0.351 0.089 3.956*** [0.176, 0.526]
Non-sexual-abstinent (1) 0.084 0.048 1.753 [0.011, 0.179]

*p < .05. **p < .01. ***p < .001.

Psychological health

5 Sexual abstinence
4
3 Non-sexual abstinence
2
1
1 2 3 4 5
Sexual Satisfaction

Figure 1. The moderating impact of sexual abstinence on the relationship

between sexual satisfaction and psychological health.

The level of sexual satisfaction predicted psychological health among the

sexually abstinent inmates. The more sexually satisfied inmates were, the
greater their psychological health. A similar, but non-significant trend (p =
.081) was found among the non-sexual-abstinent group (see Table 3). The
resulting interaction plot can be seen in Figure 1.

Discussion
This study found two main results: (a) Sexual satisfaction was lower for sexually
abstinent inmates in comparison to inmates who have had heterosexual sexual
relationships in the last 6 months, and (b) sexual satisfaction was a significant
predictor of psychological health but only for the sexually abstinent group.

Gender and Sexual Activity Level Differences in Sexual

Satisfaction
After accounting for the control variables, no differences in sexual satisfac-
tion scores were found between male and female inmates. This result contra-
dicts our first two studies (Carcedo, 2005; Carcedo et al., 2008) but supports

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Carcedo et al. 57

the findings of a more recent work (Carcedo et al., 2011) in which a set of
control variables were included. However, no control variables were included
in the other two previous studies that showed women to have a higher level
of sexual satisfaction than men (Carcedo, 2005; Carcedo et al., 2008). This
makes clear that when control variables are included, gender is no longer
significant for inmates sexual satisfaction.
In addition, the heterosexually abstinent prison inmates showed lower
sexual satisfaction than the heterosexually active group. This result is akin to
Carcedos (2005) findings. In the present study, no interaction effect of gen-
der by heterosexual activity level was found. In sum, having a sexual rela-
tionship is important for inmates psychological health, independent of the
inmate being a male or a female.

Sexual Satisfaction and Psychological Health

Independent of gender and sexual activity level, higher levels of sexual satis-
faction were associated with higher levels of psychological health. This result
is consistent with other prison studies (Carcedo, 2005; Carcedo et al., 2008;
Carcedo et al., 2012; Linville, 1981), other authors statements about prison
inmates (Lacombe, 1997; Levenson, 1983; Linville, 1981; Neuman, 1982),
and non-prison studies (Fegg et al., 2003; Lau et al., 2005; Nicolosi et al.,
2004; Taleporos & McCabe, 2002). For all of them, higher levels of sexual
satisfaction were associated with higher levels of psychological health and
other well-being-related measures.
Of all the things that influence well-being, one might question the impor-
tance of sex. The 2007 Durex Global Sexual Well-Being Survey showed that
the typical adult around the world only has sex once a week with foreplay and
intercourse averaging a mere 36 min (Durex, 2007; Wylie, 2009). Despite
this, Kahneman, Krueger, Schkade, Schwarz, and Stone (2004) found that
intimate relations are the most positively evaluated of all daily activities.
Blanchflower and Oswald (2004) add to this that the effect of sex on happi-
ness is statistically well determined, monotonic, and large, especially for
individuals under age 40 (p. 411).

The Moderating Effects of Sexual Activity Level on the

Relationship Between Sexual Satisfaction and Psychological
Health
Sexual satisfaction was a significant predictor of psychological health but
only for the sexually abstinent group. In other words, the relationship between
sexual satisfaction and psychological health is significant for the group whom

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58 The Prison Journal 95(1)

we believe were experiencing greater reactance due to their lack of choice in

their sexual behaviors. This is the first time that this result has been encoun-
tered in prison inmates. However, this finding is consistent with RT (Brehm
& Brehm, 1981) and other results found in non-prison populations whose
freedom to choose has been reduced or eliminated due to constraining situa-
tions such as the presence of sexual dysfunctions (Lau et al., 2005; Ventegodt,
1998), physical disabilities (Taleporos & McCabe, 2002), amputations
(Walters & Williamson, 1998), and having endured germ-cell tumor therapy
(Fegg et al., 2003).
The interviewers observations and the data gathered from this and another
of our previous studies (Carcedo, 2005) have relevance for understanding the
obtained interaction. Inmates who have not had sex for a long time made
more references to terms and adjectives related to sexual well-being and
expressed more anger (a concept-related to reactance) than did the inmates
who have had sex in the last 6 months. We suspect that what inmates discuss
reflects the importance they attribute to things; that is, we believe that those
who are sexually abstinent due to the conditions of prison life see sex as more
crucial to their well-being than do non-sexual-abstinent inmates. Thus, flow-
ing from these ideas and supporting our results, sexual satisfaction may be
more central for the psychological health of sexually abstinent inmates.
Notwithstanding, this result needs to be further investigated not only in prison
inmates but also in other populations with sexual problems in relation with
other individuals without these issues. The scarcity of empirical evidence
regarding the heterosexual desires and behaviors of inmates makes it espe-
cially important to focus on such populations in future studies.
The stronger relationship between sexual satisfaction and psychological
well-being among the sexually abstinent group also complements themes in
the early prison literature. The authors of these early studies discussed the
possible negative consequences of sexual abstinence for inmates health
(Levenson, 1983; Linville, 1981; Neuman, 1982; Snchez, 1995). As conju-
gal visits within prisons were even rarer than they are today, these authors
presumably were referring to inmates who had not had sex for a long time.
The present findings imply that it is for such sexually deprived inmates that
the negative mental health consequences are most pronounced, not for
inmates with greater access to and involvement in heterosexual activity.
This sexual deprivation could increase the desire for having sexual rela-
tionships, thus intensifying the impact of sexual satisfaction on psychological
health, as RT (Brehm & Brehm, 1981) posits. Thus, RT can explain why
higher levels of sexual satisfaction were associated with higher levels of psy-
chological health, although only for the inmates belonging to the sexually
abstinent group.

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Carcedo et al. 59

Future research pertaining to the sexual activity by sexual satisfaction interac-

tion might go in several directions. First, in cross-sectional studies, it would be
profitable to demonstrate that reactance is greater in populations such as inmates
whose members are prevented from having sex and that in sexually constrained
subgroups these reactance processes mediate between sexual satisfaction and
psychological health. Second, longitudinal studies of the inmates going from the
sexually abstinent group to the sexually active group (or vice versa) are war-
ranted. Consider those starting in the sexual-abstinent group: It would be valu-
able to demonstrate on a within-subject bases (a) that prior to the transition sexual
satisfaction is associated with psychological health but this association is non-
significant afterward, and (b) that sexual needs are highly important prior to the
transition but decline in importance after the transition. Third, it would be valu-
able to isolate a group of inmates who have not had sexual relationships for a long
time. If our analysis is correct, there should still be a strong sexual satisfaction/
psychological health association for this unique population. A final area for future
research might be efforts to apply RT to other deprivations of prison life.
Some heterosexually abstinent participants in this study reported relatively
higher levels of sexual satisfaction and psychological health. To fully under-
stand this, it would be beneficial to study why some inmates adjust better than
others to sexual deprivation. For instance, individuals who have had fairly nega-
tive sexual experiences in the past might not have been very interested in sex, or
individuals for whom sexual abstinence is a positive value might interpret this
situation in a more positive way, or some people may be generally more positive
in their outlook such that they judge both their sexual situation and their well-
being through positive lens. In this sense, sexual deprivation may not be consid-
ered and experienced by these individuals as necessarily negative.

The Moderating Effect of Gender on the Relationship Between

Sexual Satisfaction and Psychological Health, and Control
Variables
The moderating effect of gender on the relationship between sexual satisfac-
tion and psychological health was not found, contradicting previous non-
prison studies (Laumann et al., 2006; Taleporos & McCabe, 2002). An
association between being more sexually satisfied and having greater psy-
chological health was obtained, however, consistent with the only prison
study of which we are aware that has dealt with this relationship (Carcedo
et al., 2008). In that particular study, sexual satisfaction predicted psychologi-
cal health for both genders, although the percentage of explained variance
was slightly higher for women. Carcedo et al.s study did not statistically test
whether that difference was significant. However, the conditional effect of

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60 The Prison Journal 95(1)

sexual satisfaction in the current investigation supports and refines Carcedo

et al.s work, since a group of control variables were analyzed simultaneously
with sexual satisfaction to predict psychological health. This result is also
consistent with previous RT findings, because research in psychological reac-
tance has detected gender differences only in an insignificant portion of the
reactance literature. In this sense, psychological reactance is not gender-
specific (Brehm & Brehm, 1981).

Limitations of the Present Study

Although we think that the sample size is quite large for an interview study
focused on an uncommon topic in prison and sexuality research, the statisti-
cal power for detecting effects, especially interaction effects, is still low.
Thus caution is needed in generalizing these results to the whole prison popu-
lation. Even more caution is needed in making generalizations to the non-
prison population. More research is needed in this regard. In addition, in light
of the uneven ratio of women to men within the two sexual activity groups,
we used the model comparisons framework articulated by Appelbaum and
Cramer (1974) and Maxwell and Delaney (1990) to deal with non-orthogonality.
Still future research is needed to check if similar results are found using com-
pletely balanced or orthogonal designs.
Another limitation of this study is that causation is difficult to infer due to
the correlational design. In a recent issue of the Journal of Sex & Marital
Therapy, Balon (2008) stated that psychological health may lead to sexual
satisfaction or sexual satisfaction and psychological health may have a circu-
lar relationship. However, in the same issue, Rosen and Bachmann (2008)
used empirical evidence and the perspective of a positive psychology to argue
for a directional relationship from sexual satisfaction to well-being.
Finally, despite the interviewer stressing the confidentiality and anonym-
ity of the study, homosexual contacts might have been underreported by the
inmates. In evaluating that possibility it is important to keep in mind that all
the inmates indicated they felt very comfortable during the interview and
they disclosed other sensitive information about themselves. Future research-
ers might employ more subtle ways of seeking information about homosex-
ual acts to determine if their true rate is higher in Spanish prisons than was
reported to the current research team.

Implications and Conclusions

Finally, these results have practical implications. Allowing inmates to have
romantic and sexual relationships with other inmates in prison appears to be

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Carcedo et al. 61

a valuable option for them, especially for those without a partner. Therefore,
having this as a prison policy may be beneficial for inmates sexual satisfac-
tion and psychological health. It may also benefit prisons: Inmates scoring
higher on psychological health have lower levels of misconduct at prison
(Wright, Salisbury, & Van Voorhis, 2007). Furthermore, lower levels of per-
sonal distress, a psychological health-related concept, have been significantly
associated with lower recidivism rate after inmates are released (Gendreau,
Little, & Goggin, 1996). Thus, we would point out that housing men and
women in the same prison can be beneficial, particularly if they are allowed
to start romantic relationships and maintain sexual relationships. Nevertheless,
education and policies to control sexual risks (e.g., unwanted pregnancies,
STDs, and sexual-partner violence) also have to be developed. For example,
in the prison where this study was conducted, the prison gives condoms to
inmates every month, offers some sexual education courses, tests inmates for
STDs and HIV, supervises their relationships to prevent any possible sort of
violence, and takes into consideration the inmates criminal records.
Historically, as well as now, sexuality has all too often been left in the
shadows rather than illuminated. Myths, false beliefs, and fears have always
surrounded this topic. If we add prison, the resultant equation is even more
scary, and misconceptions are likely to proliferate. Prison systems con-
cerned with inmates needs have offered some alternatives to sexual depriva-
tion such as conjugal visits. For inmates who have no partner, however,
conjugal visits are not a viable solution. Systems such as the one we studied
that allow inmates to form relationships are needed.
Correctional systems focused on punishing inmates have adopted an easy
solution: deprivation. Independent of the prison system and the cultural view
of sexuality, the fact is that sexual satisfaction seems to be associated with
psychological health, especially for those who have not had sex for a long
time. We advocate for more research in this area, but if the present results are
supported in the future, the implication for prison policies appears clear:
Sexual activity enhances psychological health and, among those without a
partner, being satisfied with ones sexual situation enhances psychological
health. The former effect appears more powerful than the latter. Rather than be
guided by our own (mis)conceptions, let us be guided by tested knowledge.

Acknowledgments
The authors are very grateful to the regional education authority of Castilla y Len and
the Ministry of Education, Culture and Sports of Spain which provided two grants, one
to carry out this study (ref. SA007B08), and another through the Jos Castillejo pro-
gram to support the stay of the first author in the Department of Human Development
and Family Studies at the University of North Carolina at Greensboro. The first author

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62 The Prison Journal 95(1)

is also grateful to this department for their support and help with this project. Finally,
he wants to thank Ioana Scripa for her help in preparing the manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: The authors received financial support
for the research from the regional education authority of Castilla y Len (Junta de
Castilla y Len, ref. SA007B08). The first author also received a grant from the
Ministry of Educacin, Culture and Sports of Spain to support his stay in the
Department of Human Development and Family Studies at the University of North
Carolina at Greensboro.

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Author Biographies
Rodrigo J. Carcedo is an associate professor in the Department of Developmental
and Educational Psychology, University of Salamanca. His research focuses on inter-
personal and sexual needs related to prisoners and other socially excluded popula-
tions. His research has been published in The International Journal of Offender
Therapy & Comparative Criminology, The Spanish Journal of Psychology,
Adicciones, Behavioral Psychology, and Sex Education: Sexuality, Society and
Learning.
Daniel Perlman is a professor of human development & family studies, University of
North Carolina at Greensboro. He is co-author of a textbook, Intimate Relationships,
and co-editor of the Cambridge Handbook of Personal Relationships. He has also
published his work in prestigious journals such as Criminal Justice and Behavior,
Journal of Social Issues, Archives of Sexual Behavior, Personality and Social
Psychology Bulletin, and Journal of Social and Personal Relationships. He has also
served as president of four professional associations.
Flix Lpez is professor in the Department of Developmental and Educational
Psychology, University of Salamanca. A senior scientist, his research interests are
sexuality and interpersonal relationships needs theory, infancy, adolescence, and
socially excluded populations. He has recently published in The International Journal
of Offender Therapy & Comparative Criminology, The Spanish Journal of Psychology,
Psicothema, and Infancia y Aprendizaje.
M. Begoa Orgaz is an associate professor in the Department of Methodology of
Behavioral Sciences, University of Salamanca. A data analyst, her most recent publi-
cations have appeared in The International Journal of Offender Therapy &
Comparative Criminology, Behavioral Psychology, BMC Pediatrics Journal, and
Computers in Human Behavior.
Noelia Fernndez-Rouco is an assistant professor in the Department of Education,
University of Cantabria. Her research interests include well-being in transsexual,
homosexual, and prison inmate populations, and needs theory. Her most recent pub-
lications are a book and an article in The International Journal of Offender Therapy
and Comparative Criminology.

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