Can I Ask for Help? The Relationship Among Incarcerated Males’ Sexual Orientation,Sexual Abuse History,and Perceptions of Rape in Prison

Abstract

In 2003, Congress passed the Prison Rape Elimination Act (PREA). Although subsequent research to PREA has shed light on the prevalence and incidence of sexual violence in American prisons, few studies examine inmates’ perceptions of rape and safety from rape in prison. Even less is known about how inmates’ perceptions of rape influence mental health treatment–seeking behavior during incarceration. Using a sample of incarcerated men, this study adds to the limited body of research by examining the perceived fear of rape and mental health treatment–seeking behavior in two vulnerable prison populations—gay and bisexual inmates and inmates with a history of childhood sexual abuse. Compared with straight inmates, gay and bisexual inmates were approximately two times more likely to perceive that rape was a threat and three times more likely to voluntarily request mental health treatment in prison. Inmates with a history of childhood sexual abuse were over twice as likely to perceive the threat of rape and nearly four times more likely to request mental health treatment than inmates who did not report a history of childhood sexual abuse. Policy, practice implications, and recommendations for future research are discussed.

Keywords

offenders sexual assault male victims violence exposure child abuse cultural contexts GLBT

Introduction

In 2003, the U.S. Congress passed the Prison Rape Elimination Act (PREA; P.L. 108-79), which aimed to establish a zero tolerance policy toward prison rape and minimize sexual violence in correctional facilities. Part of this legislation required government agencies to determine the prevalence of sexual violence in correctional facilities across the United States. Although rates of sexual assault in correctional facilities appear low and have declined since 2007, vulnerable prison populations, including gay and bisexual inmates (Beck, Berzofsky, Caspar, & Krebs, 2013; Hensley, Koscheski, & Tewksbury, 2005), those with a history of childhood sexual abuse (CSA; Wolff, Blitz, & Shi, 2007), and transgender inmates (Jenness & Fenstermaker, 2016; Jenness, Maxson, Matsuda, & Sumner, 2007) are at elevated risk of sexual victimization. The most recent National Inmate Survey of 2011-2012 shows that among nonheterosexual prison inmates, 12.2% reported sexual victimization by another inmate and 5.4% by staff within the past 12 months, or since admission if an inmate was incarcerated for fewer than 12 months. In comparison, 1.2% of heterosexual prisoners reported being sexually victimized by another inmate and 2.1% by staff in the same time period (Beck et al., 2013). Inmates with mental illness had higher rates of inmate-on-inmate (Austin, Fabelo, Gunter, & McGinnis, 2006) and staff-on-inmate sexual victimization (Beck et al., 2013). Given these statistics, fear of rape, especially for those at risk of victimization, is a factor that can critically affect inmates’ psychological well-being (Maitland & Sluder, 1998; McCorkle, 1993).

Sexual violence in prison plays a large role in shaping the power hierarchy among prison populations. For male inmates, sexual victimization is associated with involvement in other sexual activity, such as bartered or consensual sexual relationships. Furthermore, those who are sexually victimized may engage in future sexually predatory behavior (Warren, Jackson, Booker, & Burnette, 2009). Despite the impact that fear of victimization has on mental health and behavior, many inmates are reluctant to seek treatment. Inmates note deterrents such as the lack of mental health services and being perceived as weak (Kupers, 2005; Morgan, Rozycki, & Wilson, 2004; Morgan, Steffan, Shaw, & Wilson, 2007). Inmates’ choice to avoid seeking needed mental health treatment can have consequences that include worsening mental health symptoms, lack of accurate diagnoses and treatment, and substance abuse—all known risk factors for recidivism (Andrews, Bonta, & Wormith, 2006). Moreover, leaving inmates’ mental health issues unaddressed may affect underresourced community health systems upon their release (Brinkley-Rubinstein, 2013).

There is a paucity of research regarding factors associated with inmates’ decision to voluntarily request mental health treatment in prison. Diamond, Magaletta, Harzke, and Baxter (2008) found that a history of mental health treatment in the community was the strongest predictor of requesting treatment upon admission to prison, with approximately 9% of male inmates submitting requests. Their study, however, did not examine the role of CSA history—a factor associated with psychological symptoms in males (O’Leary, Easton, & Gould, 2017). In addition, whereas some studies find that inmates at risk of being sexually assaulted perceive their risk to be elevated (Tewksbury, 1989), others suggest that at-risk inmates, such as those with a CSA history, do not experience increased levels of fear of victimization (Wolff & Shi, 2009). The current study builds upon the existing literature and examines factors related to fear of rape in prison and the likelihood of male inmates requesting mental health treatment while incarcerated, focusing specifically on prisoners at risk of being sexually victimized in prison: gay or bisexual inmates and those with a history of CSA. The current study utilizes data from over 400 general population male inmates housed in 23 maximum-security prisons across the United States. We first explore factors related to male inmates’ perceptions of rape as a threat in prison, focusing on whether sexual orientation and CSA history are associated with their fear of rape. We then examine if sexual orientation, CSA history, perceiving rape as a threat in prison, and seeking mental health treatment are interrelated.

Literature Review

Fear of Sexual Abuse Among Incarcerated Men

It is well documented that people who experience CSA are at increased risk for mental and physical health issues in adulthood (e.g., Dube et al., 2005). Furthermore, male inmates with a CSA history are between 2 and 5 times more likely to report sexual victimization inside prison than inmates who do not (Wolff et al., 2007), though they may not be more likely to fear sexual violence (Wolff & Shi, 2009). Wolff and Shi’s (2009) finding warrants further exploration, including an examination of the influence of CSA as well as sexual orientation—a critical component of prison sexual violence. Approximately 6% of male inmates report sexual abuse prior to admission to prison, with 5% experiencing this abuse before age 18 (Harlow, 1999). Though these estimates are equal to community estimates of penetrative male CSA and lower than estimates of nonpenetrative abuse among males (Gilbert et al., 2009), researchers widely acknowledge that there is incentive for incarcerated men to underreport sexual abuse (Kupers, 2005; Wolff et al., 2007). Males, including gay men, who have experienced CSA are more likely to be revictimized as adults (Balsam, Lehavot, & Beadnell, 2011; Desai, Arias, Thompson, & Basile, 2002). Revictimization of males with a CSA history may be attributed to patterns of vulnerability beginning in childhood and increased difficulty in forming healthy social relationships (Desai et al., 2002).

Regardless of their sexual abuse history, inmates are more likely to experience mental anguish if they are fearful of sexual victimization (McCorkle, 1993). Simply being exposed to sexual abuse (e.g., witnessing or knowing about incidents of sexual violence) is associated with inmates’ fear of being victimized in prison (Worley, Worley, & Mullings, 2010). Prison staff are responsible for enforcing correctional policies and keeping inmates safe from sexual violence and other threats (Connor & Tewksbury, 2013). Rather than assuaging fears about sexual violence, officers may instill anxiety among prisoners by telling inmates, particularly new male inmates, about rape in prison and indicating that sexual violence is a part of prison life or their punishment (Fleisher & Krienert, 2006). In addition, staff may directly threaten inmates or perpetrate sexual violence in prisons (Beck et al., 2013). As officers are key actors in the process of screening inmates for housing and protections upon admission under PREA guidelines, they are in a position to either protect at-risk inmates by assigning them to protective housing (Connor & Tewksbury, 2013) or threaten them by assigning housing with known sexual predators (Fleisher & Krienert, 2006). Fear of rape is consequently a driving force that shapes social behaviors in prison (Fleisher & Krienert, 2006; Tewksbury, 1989). Inmates who fear sexual violence may avoid areas outside their cells that are associated with rape, such as showers, dorms, and common areas (Austin et al., 2006). In addition, incarcerated men who fear rape may engage in harmful behavior, such as participating in protective pairing, in which an inmate exchanges sexual favors for the protection of another inmate (Trammell, 2011).

Cultural Factors Surrounding Sexual Victimization Among Gay and Bisexual Inmates

Trauma related to sexual victimization and fear of assault are central to the experience of gay and bisexual men both in correctional settings (Browne, Hastings, Kall, & DiZerega, 2015) and in the community (Cramer, McNiel, Holley, Shumway, & Boccellari, 2012). Gay and bisexual inmates are often relegated to positions of low power and are more likely to be perceived as targets for sexual victimization than their heterosexual counterparts (Fleisher & Krienert, 2006). In addition, officers and inmates may perceive men who are victims of sexual assault as homosexual regardless of their identified orientation, which can contribute to their loss of social power (Fleisher & Krienert, 2006). Thus, victimization alone can increase an inmate’s risk of being targeted by future perpetrators.

Screening inmates for risk of sexual victimization is a critical aspect of PREA. Correctional officers are required to recognize and protect high-risk populations (PREA, 2003). Bias, however, can affect the implementation of protective measures. Correctional officers may demonstrate less concern about sexual violence in prison among male inmates than among female inmates (Beck & Harrison, 2007). Both officers and inmates may be more permissive of sexual assault against openly gay male inmates under the premise that male-to-male sexual contact, albeit coerced, is something they enjoy (Fleisher & Krienert, 2006). Even efforts by officers to keep at-risk inmates safe by segregating them from potential perpetrators can lead to adverse psychological consequences associated with segregation (Haney, 2003).

Factors Affecting Inmates’ Decision to Seek Mental Health Treatment

Prisoners are disproportionately affected by mental illness (Magaletta, Diamond, Faust, Daggett, & Camp, 2009), and mental health issues and sexual victimization are closely linked in correctional settings. Approximately one in 12 inmates with a mental disorder report at least one incident of sexual victimization by another inmate over a 6-month period, compared with one in 33 male inmates without a mental disorder (Wolff et al., 2007). Prisoners are also more likely to have witnessed acts of violence than the general population (Hochstetler, Murphy, & Simons, 2004). Researchers have noted, in other contexts, that witnessing violence may contribute to internalizing and externalizing mental health outcomes such as fear and displaying aggression (Blair, McFarlane, Nava, Gilroy, & Maddoux, 2015). Despite these troubling patterns, some estimates suggest that while approximately 15% of state inmates have identified mental health needs (Magaletta et al., 2009), only one in three state prisoners with mental illness receive treatment services (James & Glaze, 2006).

Morgan and colleagues (2004) found that approximately a third of their sample of over 400 male inmates reported voluntarily participating in mental health services during their incarceration, with maximum-security prisoners voluntarily participating at higher rates than their peers housed in less restrictive settings. In addition, inmates with a history of mental health treatment services in the community were more likely to have received services in prison (Morgan et al., 2007). Inmates with a history of psychiatric treatment, symptoms of anxiety and depression (i.e., nervousness, suicidality, and hopelessness), and physical or medical problems were more likely than their peers to request treatment (Diamond et al., 2008; Morgan et al., 2007). Notably, these studies did not examine the role of sexual orientation and CSA in predicting mental health treatment–seeking behavior.

Despite these identified needs, inmates face barriers to service utilization. Inmates may be skeptical of the quality of treatment in correctional settings and perceive seeking mental health treatment as having negative social consequences (Morgan et al., 2007). Indeed, Kupers (2005) found that the masculine culture of prison discourages male inmates from seeking treatment in prison. Although some research has highlighted institutional barriers to care, such as limited health care resources (Brinkley-Rubinstein, 2013), less is known about factors associated with inmates’ choice to seek treatment on their own (Diamond et al., 2008). Collectively, these issues suggest that studying perceived threat of rape and CSA history is crucial to a fuller understanding of factors affecting inmates’ mental health and mental health treatment in prison.

Current Study

Since the passage of PREA, research on sexual violence in prisons has revealed several factors associated with inmates’ elevated risk of victimization and mental health issues, including, but not limited to, a history of CSA (Wolff et al., 2007) and identifying as gay or bisexual (Beck et al., 2013). This study seeks to extend the literature by exploring perceptions of rape and mental health treatment–seeking behaviors among vulnerable male inmates incarcerated in maximum-security correctional facilities throughout the United States. First, this study explores factors relating to male inmates’ perceptions of rape as a threat in prison and focuses on whether sexual orientation and CSA history are associated with fear of rape. The study then explores if sexual orientation, CSA history, perceiving rape as a threat in prison, and voluntarily requesting mental health treatment in prison are related. The findings have the potential to further understanding of vulnerable inmates’ perceptions of rape and treatment–seeking behavior and provide implications for policy and practice. The following two research questions are the focus of this study:

Research Question 1: To what extent are sexual orientation and having a history of CSA associated with perceptions that rape is a threat in prison?

Research Question 2: To what extent do sexual orientation, having a history of CSA, and perceptions of prison rape predict the likelihood of voluntarily requesting mental health treatment in prison?

Method

Data

The current study utilized data collected for Fleisher and Krienert’s (2006) qualitative ethnomethodological study on the culture of prison sexual violence and inmate sexuality. The data were obtained from the Interuniversity Consortium for Political and Social Research (ICPSR)—a database of publicly available information relevant to social science. In the original study, data were collected from male offenders¹ in state correctional institutions in 10 states.²

Sampling Method

Fleisher and Krienert (2006) utilized a random start and fixed selection-interval probability sample design to select their sample of general population inmates.³ The number of general population inmates on a correction institution’s sample roster was divided by the number of projected interviews that could be conducted in a week. After obtaining the sampling roster, a research team member chose a number (n) at random between one and the interval number, which corresponded to an inmate on the sampling roster. The remaining inmates were chosen by selecting every nth inmate on the roster. Then, 15 to 20 inmates were added per institution to account for interview refusals, inmate transfers, medical care, and other unexpected circumstances that prevented successful completion of study participation.

Interview Procedure

Once inmates were selected to participate in the study, they were either given a pass or asked to report for study participation on the day of data collection. Inmates were then escorted by a researcher to the interview room. Inmates provided informed consent for their participation in Fleisher and Krienert’s (2006) qualitative study discussing sensitive topics related to sexual assault in prison. Interview content was developed based on themes identified in PREA and published prison sex and rape literature available at the time of data collection. The definition of rape was determined by the language and conceptualization used in PREA. Interview content was also determined by themes related to prison sexual culture and sexual violence that arose during a panel discussion with former inmates who had spent between 10 and 15 years in prison.

All interviews were conducted in private rooms within the institution, outside of the view of staff, inmates, or other interview rooms. Interviewers stressed that the interviews were voluntary, inmates could refuse to answer any question(s), inmates could end the interview at any time, and early termination of an interview would not lead to a penalty implemented by the institution. On average, the semistructured interviews were completed in under an hour. Surveys were designed with each query resting on a particular concept or variable. Data were collected via transcriptions of the face-to-face interviews with inmates. To provide quantitative data, the co-principal investigator identified survey questions that would yield quantifiable information. Answers for the selected questions were taken from each interview and entered into SPSS. These data are the basis for the current research. Further detail about the original study, including inclusion and exclusion criteria, sampling method, and interviewing procedure, can be obtained in Fleisher and Krienert’s (2006) full report, The Culture of Prison Sexual Violence.

Description of Variables

Dependent variables

This study included two primary variables of interest. The first dependent variable is belief that rape is a “big threat.” During the qualitative interviews, participants were asked, “Are people worried about rape?” followed by “Is it a big threat?” Inmates who answered yes to either of these questions in their qualitative interviews were dichotomized as yes (coded as “1”), with all others being dichotomized as no (coded as “0”). This variable was also included as an independent variable in the subsequent logistic regression model examining inmates’ likelihood to have voluntarily requested mental health treatment in prison.

The second dependent variable is whether inmates voluntarily requested mental health treatment. Participants were asked, “Have you ever voluntarily requested mental health treatment in prison?” Responses were then dichotomized as yes (coded as “1”) and no (coded as “0”).

Independent variables

The first independent variable of interest is sexual orientation. Participants were asked to identify their street sexual orientation, operationalized as sexual orientation while living in the community. In Fleisher and Krienert’s (2006) original study, male respondents chose among straight, gay, and bisexual. For the purpose of this study, the categories “gay” and “bisexual” are combined into a dichotomous variable—gay/bisexual. This allows for analyses examining whether self-identification as a sexual minority affects inmates’ perceptions regarding the threat of rape in prison. Responses were dichotomized as gay/bisexual (coded as “1”) and straight (coded as “0”).

The second independent variable of interest is history of CSA. Participants were asked, “When you were coming up, did an adult, relative, friend or someone you trust sexually abuse you?” Responses were dichotomized as yes (coded as “1”) and no (coded as “0”).

Control variables

Multiple control variables were included, including race, age at time of interview, age at time of first incarceration in the adult criminal justice system, total years spent in state prison, history of juvenile detention, and history of mental health treatment in the community.

Race

Participants were asked about their identified race. Response options included White (reference category), Black, Hispanic, and Other. For the purpose of the original study, Hispanic was coded as a distinct race as opposed to ethnicity. Variables were dichotomized as yes (coded as “1”) and no (coded as “0”) for each category.

Age at the time of interview

The age of each inmate at the time of interview was recorded categorically in the data set. For analysis, age was categorized as follows: 29 and younger (reference category), 30 to 39, 40 to 49, and 50 and older. Each age category was dichotomized as yes (coded as “1”) and no (coded as “0”).

Age at the time of first incarceration in adult criminal justice system

Participants were asked the age at which they were first admitted to adult prison. Their ages were categorically coded as follows: 18 or younger, 19 to 24, and 25 and older (reference category). Each age category was dichotomized as yes (coded as “1”) and no (coded as “0”).

Total years spent in state prison

The total number of years that each participant had spent in state prison was recorded. Responses were coded categorically: 0 to 2 years (reference category), 2 to 5 years, 5 to 10 years, 10 to 18 years, and 18 years and more. Each length of incarceration history category was dichotomized as yes (coded as “1”) and no (coded as “0”).

History of juvenile detention

Participants were asked if they had ever been to juvenile detention. Responses were dichotomized as yes (coded as “1”) and no (coded as “0”).

History of mental health treatment in the community

Participants were asked, “Have you ever been treated for mental health issues on the street as a result of something you did in school or in your family or neighborhood?” Responses were dichotomized as yes (coded as “1”) and no (coded as “0”).

Analytic Plan

As per the data processing protocol of ICPSR, missing values were standardized, and the data were checked for undocumented or out-of-range values. Bivariate analyses were conducted utilizing chi-square tests of independence to examine whether significant relationships existed between the dependent and independent variables. Binary logistic regression models were used to examine (a) the effects of sexual orientation and CSA on perceptions of the threat of rape in prison and (b) the effects of sexual orientation, CSA, and perceptions of the threat of rape on the likelihood of requesting mental health treatment.

Results

Participant Characteristics

Data were available for 409 male inmates housed in 23 maximum-security prisons in the United States. As indicated in Table 1, the sample consisted of a nearly equal number of men in their 20s, 30s, and 40s. Black inmates made up nearly half of the sample (n = 202), with White inmates comprising over one third of the sample (n = 154). Approximately one third of the sample had previously been in juvenile detention, and approximately one quarter were incarcerated for the first time in the adult criminal justice system at age 18 or younger. The sample consisted of nearly an equal percentage (approximately 20%) of men incarcerated fewer than 2 years, 2 to 5 years, 5 to 10 years, 10 to 18 years, and 18 years and more.

Table 1.

Participant Descriptive Statistics (N = 409).

Variable	n	%
Dependent variables
Rape is a big threat in prison	80	21.3
Voluntarily requested mental health treatment in prison	127	35.4
Independent variables
Sexual orientation
Gay/bisexual	67	16.4
Straight	342	83.6
History of childhood sexual abuse	73	20.3
Control variables
Race
Black	202	49.4
Hispanic	42	10.3
White	154	37.7
Other	11	2.7
Age at the time of interview
29 and younger	117	28.6
30-39	134	32.8
40-49	113	27.6
50 and older	45	11.0
Age first incarcerated in the adult system
18 and younger	102	24.9
19-24	167	40.8
25 and older	140	34.2
Total years in state prison
0-2 years	84	20.5
2-5 years	91	22.2
5-10 years	76	18.6
10-18 years	86	21.0
18 years and more	72	17.6
Ever been to juvenile detention	133	32.5
History of mental health treatment in the community	115	32.2

Note. All variables were coded as 0 = no, 1 = yes.

In addition, 16.4% of the sample (n = 67) identified as gay or bisexual. None of the men in the sample identified as transgender, a population known to be at high risk of rape in prison (Jenness et al., 2007). Approximately, one fifth of men in the current study reported a history of CSA (n = 73), and nearly one third (32.2%, n = 115) of the men in the sample reported having received mental health treatment in the community. A minority (21.3%, n = 80) of incarcerated men in the sample believe that rape is a big threat in prison, and over 35% (n = 127) of inmates in the sample had voluntarily requested mental health treatment. Notably, while 18% (n = 58) of heterosexual inmates in the current sample perceived rape to be a big threat, a significantly larger percent of gay and bisexual inmates perceived rape to be a big threat (37.9%, n = 22). In addition, approximately 16% (n = 43) of inmates without a history of CSA perceived rape to be a big threat, while almost 37% (n = 25) of inmates with a CSA history perceived rape to be a big threat.

Chi-square tests of independence were conducted to examine if there is a significant relationship between each pair of independent and dependent variables of interest and if the control variables were significantly associated with the dependent variables. Results indicate that sexual orientation, having a history of CSA, and a history of mental health treatment in the community are each significantly related to perceiving that rape is a big threat in prison (see Table 2). Race is also significantly associated with perceiving a big threat of rape in prison.

Table 2.

Crosstabulation of Rape Is a Big Threat Among Independent and Control Variables (N = 409).

Variable	Rape Is a Big Threat				χ²	df	n	Effect Size
Variable	No	%	Yes	%	χ²	df	n	Effect Size
Sexual orientation
Gay/bisexual	36	9.60	22	5.87	11.26*	1	375	.17
Straight	259	69.07	58	15.47
History of childhood sexual abuse
No	227	67.16	43	12.72	14.68**	1	338	.21
Yes	43	12.72	25	7.40
Race
Black	154	41.07	32	8.53	7.93*	3	375	.15
Hispanic	29	7.73	11	2.93
White	107	28.53	32	8.53
Other	5	1.33	5	1.33
Age at time of interview
29 and younger	83	22.13	21	5.60	.80	3	375	.05
30-39	97	25.87	27	7.20
40-49	84	22.40	21	5.60
50 and older	31	8.27	11	29.33
Age first incarcerated in the adult system
18 and younger	69	18.40	25	6.67	2.58	2	375	.08
19-24	119	31.73	32	8.53
25 and older	107	28.53	23	6.12
Total years in state prison
0-2	65	17.33	11	2.93	6.50	4	375	.13
2-5	65	17.33	22	5.87
5-10	58	15.47	10	2.67
10-18	60	16.00	22	5.87
18 and older	47	12.53	15	4.00
Ever been in juvenile detention
No	209	5.57	49	1.07	2.70	1	375	.09
Yes	86	22.93	31	8.27
History of mental health treatment in the community
No	198	5.84	33	9.73	15.07**	1	339	.21
Yes	73	2.53	35	10.32

p < .05, **p < .01.

In Table 3, there are significant relationships between (a) sexual orientation, (b) history of CSA, and (c) rape is a big threat in prison and having voluntarily requested mental health treatment. Incarcerated men who identify as gay or bisexual, those who perceive that rape is a big threat in prison, and those with a history of CSA requested mental health treatment in prison at higher rates. Data reveal that a positive significant relationship also exists between a history of mental health treatment in the community and having voluntarily requested mental health treatment in prison. However, there was no significant statistical relationship between a history of juvenile incarceration history or the age first incarcerated in the adult system and having requested mental health treatment in prison.

Table 3.

Crosstabulation of Having Voluntarily Requested Mental Health Treatment in Prison Among Independent and Control Variables (N = 409).

Variable	Voluntarily Requested Mental Health Treatment in Prison				χ²	df	n	Effect Size
Variable	No	%	Yes	%	χ²	df	n	Effect Size
Rape is a big threat
No	188	55.46	83	24.48	11.88**	1	339	.19
Yes	32	9.44	36	10.61
Sexual orientation
Gay/bisexual	209	58.31	94	26.18	16.10*	1	359	.21
Straight	23	6.41	33	9.19
History of childhood sexual abuse
No	203	56.86	81	22.69	27.90**	1	357	.28
Yes	28	7.84	45	12.61
Race
Black	118	32.87	16.43	16.43	2.56	3	359	.08
Hispanic	21	5.85	4.18	4.18
White	89	24.79	13.37	13.37
Other	4	1.11	1.39	1.39
Age at time of interview
29 and younger	64	17.83	34	9.47	3.61	3	359	.10
30-39	77	21.45	42	11.70
40-49	69	19.22	31	8.64
50 and older	22	6.13	20	5.57
Age first incarcerated in the adult system
18 and younger	52	14.48	28	7.80	.03	2	359	.01
19-24	98	27.30	53	14.76
25 and older	82	22.84	46	12.81
Total years in state prison
0-2	56	15.60	24	6.69	6.02	4	359	.13
2-5	59	16.43	24	6.69
5-10	42	11.70	25	6.96
10-18	44	12.26	27	7.52
18 and older	31	8.64	27	7.52
Ever been in juvenile detention
No	165	45.96	87	24.23	.27	1	359	.03
Yes	67	18.66	40	11.14
History of mental health treatment in the community
No	191	53.50	51	14.26	64.15**	1	357	.42
Yes	41	11.48	74	20.73

p < .05, **p < .01.

Binary logistic regression models were used to test the two research questions, which asked to what extent sexual orientation and having a history of CSA are associated with perceptions that rape is a big threat in prison (Model 1) and to what extent sexual orientation, having a history of CSA, and perceptions of rape as a big threat in prison predict the likelihood of voluntarily requesting mental health treatment in prison (Model 2). Data were checked for multicollinearity prior to analysis; all tolerance values were above the cutoff value of .10, and variance inflation factor (VIF) values were under 10. Results indicate that both models are significantly different from the baseline models with no predictors, Model 1: χ²(16, N = 338) = 43.47, p < .001; Model 2: χ²(17, N = 338) = 107.05, p < .01. Model 1 as a whole correctly classified 83.4% of cases, with pseudo-R² values ranging between .12 (Cox and Snell R²) and .19 (Nagelkerke R²). Model 2 as a whole correctly classified 76.3% of cases, with pseudo-R² values ranging between .27 (Cox and Snell R²) and .37 (Nagelkerke R²).

Results in Table 4 indicate that sexual orientation significantly predicts perceiving that rape is a big threat in prison (Model 1). Incarcerated men who identify as gay or bisexual are over twice as likely to perceive that rape is a big threat in prison compared with straight inmates. Males with a history of CSA are 2.5 times more likely to endorse that rape is a big threat than incarcerated men without a childhood abuse history. Results also indicate that inmates who have been incarcerated for two to five years are nearly three times more likely to perceive that rape is a big threat compared with inmates incarcerated for fewer than two years. A history of incarceration in juvenile detention and age at the time of first incarceration in the adult criminal justice system do not significantly predict perceiving that rape is a big threat.

Table 4.

Logistic Regression Results for Predictors of Perceptions That Rape Is a Threat in Prison and Voluntarily Seeking Mental Health Treatment.

Variable	Model 1: Perception That Rape Is a Big Threat in Prison			Model 2: Voluntarily Seeking Mental Health Treatment
Variable	B	Exp(B)	SE	B	Exp(B)	SE
Rape is a big threat in prison		—	—	0.29	1.34	.35
Gay/bisexual	0.78	2.17*	.38	1.12	3.06**	.40
History of childhood sexual abuse	0.92	2.50**	.35	1.31	3.69***	.36
Race
Black	−0.35	0.70	.34	0.82	2.28*	.37
Hispanic	0.45	1.57	.47	0.39	1.47	.49
Other	1.12	3.06	.79	1.00	2.73	.86
Age at time of interview
30-39	0.09	1.10	.47	−0.67	0.51	.43
40-49	0.10	1.10	.54	−0.93	0.40	.49
50 and older	0.87	2.38	.65	0.25	1.28	.58
Age first incarcerated in the adult system
18 and younger	0.51	1.67	.47	−0.40	0.67	.45
19-24	0.13	1.14	.40	−0.51	0.60	.36
Total years in state prison
2-5	1.05	2.86*	.48	0.33	1.39	.44
5-10	0.25	1.29	.56	0.73	2.06	.46
10-18	0.76	2.19	.54	0.83	2.29	.48
18 and older	0.64	1.91	.65	1.31	3.67*	.59
Ever been to juvenile detention	0.18	1.20	.34	−0.07	0.93	.32
History of mental health treatment in the community	0.81	2.25**	.31	1.94	6.99***	.30
Constant	−3.01	0.05***	.61	−2.16	0.12***	.52
Nagelkerke R²	.19			.37

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

With regard to inmates voluntarily requesting mental health treatment in prison (Model 2), data reveal that gay and bisexual incarcerated males are over three times more likely than straight inmates to voluntarily request mental health treatment in prison. Having a history of sexual abuse was significantly associated with voluntarily requesting mental health treatment in prison, where men with a history of CSA are nearly four times more likely than men without a CSA history to seek mental health treatment while incarcerated. Furthermore, Black inmates are over twice as likely to seek mental health treatment in prison compared with White inmates. Consistent with expectations, incarcerated men with a history of mental health treatment in the community are nearly seven times more likely to request mental health treatment while incarcerated than those without any previous community treatment. In addition, inmates who have been incarcerated longer than 18 years are almost four times more likely to voluntarily request mental health treatment in prison than men who have been incarcerated for fewer than two years. Age at the time of first incarceration in the adult system, juvenile incarceration history, and perceiving that rape was a big threat in prison were not significantly related to voluntarily requesting mental health treatment in prison.

Discussion

Since the passage of PREA in 2003, the prevalence of sexual violence in prison has become a focus of attention of policy makers and researchers (Browne et al., 2015). The rate of sexual victimization in prison is even higher for vulnerable prison populations, including gay and bisexual inmates (Beck et al., 2013) and those with a history of CSA (Wolff et al., 2007). Although research on the prevalence and incidence of sexual violence in prison has grown in the past decade, far fewer studies examine the contextual factors surrounding prison rape (Warren et al., 2009). Prison staff and inmates in positions of power use the threat of rape as a means of control (Warren et al., 2009), and the incidence and threat of sexual violence are strong social forces in prison society (Fleisher & Krienert, 2006). Although the prevalence of rape in prison hovers around 1% for heterosexual inmates and around 12% for nonheterosexual inmates (Beck et al., 2013), approximately a fifth of the current study’s sample perceived rape to be a threat in prison, regardless of sexual orientation. In addition to being more likely to be sexually victimized in prison (Warren et al., 2009), gay and bisexual inmates and inmates with a history of CSA perceived rape to be a big threat in prison at higher rates than nonvulnerable prison populations. These findings hold true in the multivariate logistic regression model (Model 1); notably, these results are inconsistent with previous research indicating that there was no significant relationship between CSA and feelings of safety from sexual assault among male inmates (Wolff & Shi, 2009). However, Wolff and Shi’s (2009) findings are limited to a correctional system in a single state, whereas the current study samples from correctional settings across the United States. Furthermore, Wolff and Shi (2009) did not examine the role of sexual orientation. Social and institutional factors, such as inmate and staff interpersonal relationships, could have influenced inmates’ perceptions of safety and accounted for this difference (Wolff & Shi, 2009). The consequences of perceiving rape to be a threat in prison are vast for correctional staff and the well-being of incarcerated individuals. Higher prison rape awareness may contribute to violence among inmates (Worley et al., 2010) as well as negative mental health consequences for inmates including increased fear, psychological distress, chronic anxiety, depression, and suicidal ideation related to the stress of targeted sexual aggression (Haney, 2012). Despite mental illness disproportionately affecting the U.S. prison population (James & Glaze, 2006), research examining factors related to inmates’ decisions to seek mental health treatment is limited.

Findings from the logistic regression model suggest that inmates who perceive rape as a big threat in prison are no more likely than those who do not perceive rape as a big threat to voluntarily seek mental health treatment while incarcerated. This finding is interesting given the previous research in this area, which suggests that inmates’ fear of rape in prison can contribute to mental health issues (Maitland & Sluder, 1998; McCorkle, 1993). This finding, however, could be due to the fact that the measure of perceiving rape to be a big threat in prison did not directly measure the inmate’s personally perceived threat of rape. Instead, questions regarding perceived threat of rape were general queries (i.e., “Are people worried about rape?”). If questions were more specific, such as asking the inmate whether he personally fears rape, it is possible that findings could reach values of significance. We discuss this in more detail in the “Limitations” section below.

As in previous studies (Diamond et al., 2008; Morgan et al., 2007), incarcerated men with a history of mental health treatment in the community were almost seven times more likely to seek mental health treatment in prison. Length of time in prison was also a significant predictor of seeking mental health treatment in prison. Men who were incarcerated more than 18 years were more likely to have voluntarily requested mental health treatment in prison than those who had been incarcerated for zero to two years. This is expected, as inmates with longer incarcerations would have had more time to request mental health treatment than those with shorter periods of incarceration. Men who experience CSA are more likely to experience adverse mental health outcomes, such as suicidality and posttraumatic stress disorder (PTSD; Browne et al., 2015), which could result in increased treatment needs in the community and in prison. The current study extends the literature and examines the relationship between CSA and mental health treatment–seeking behavior. Notably, having a CSA history was predictive of seeking mental health treatment in prison.

Moreover, results revealed that inmates who identified as gay or bisexual were over three times more likely than straight inmates to seek mental health treatment. In the current study, Black inmates were over twice as likely as White inmates to seek mental health treatment. This finding is consistent with Diamond et al.’s (2008) study demonstrating that Black male inmates request mental health treatment at higher rates than their White counterparts upon admission to prison. These findings are interesting given national statistics indicating that White inmates have higher rates of mental health problems in prison than Black inmates (James & Glaze, 2006). This underscores the importance of obtaining a more nuanced understanding regarding the discrepancy between mental health issues and mental health service utilization among different groups of prisoners. These results may be attributed to the role of masculinity in the prison social structure. Kupers (2005) noted that valuing masculinity was one of the main barriers to seeking mental health treatment in prison. Gay and bisexual inmates are perceived to be weaker and more feminine than straight inmates, and White inmates are generally viewed as weaker than Black inmates (Fleisher & Krienert, 2006). Gay and bisexual may not be as concerned about maintaining a masculine appearance to other inmates and may be less reluctant to ask for mental health treatment. Conversely, White, straight inmates may be more hesitant than Black inmates to show signs of weakness by asking for mental health treatment.

Policy and Program Implications

Results from the current study have implications for creating practice and policy that recognize the needs of diverse groups of inmates. The key finding emerging from this study is that sexual orientation and a history of CSA are significant predictors of male inmates perceiving that rape is a big threat and voluntarily requesting mental health treatment in prison. PREA requires that inmates who are part of at-risk groups, including gay and bisexual inmates, be screened for appropriate housing and services upon their first entrance to prison and jail. Knowing that gay and bisexual inmates are more likely to fear rape and seek mental health treatment, prison staff can target outreach and treatment efforts for this vulnerable subpopulation. Policy should be enacted to educate staff and inmates on the realities of sexual violence in prison, including factors that affect inmates’ risk of sexual victimization and likelihood to seek mental health intervention on their own. While the goal of policy should be to keep all inmates safe and secure, disseminating information about the facts of prison sexual violence can help at-risk inmates, including those who identify as gay or bisexual and those with a history of CSA, recognize their elevated likelihood of victimization.

Clinicians can also provide interventions that are culturally sensitive to these populations while directly addressing the mental health consequences of fearing rape. Prison staff can screen inmates for a history of CSA and provide appropriate referrals for services. If vulnerable inmates are made aware of barriers to requesting treatment, they may better recognize what is preventing them from asking for help. The current study shows that these subgroups of vulnerable inmates are receptive to requesting treatment.

Limitations

The findings of the current study should be understood within the context of its limitations. This study employed a cross-sectional and correlational design. Although the logistic regression models revealed that sexual orientation and CSA history are predictive of perceiving that rape is a big threat and voluntarily requesting mental health treatment in prison, the time order of perceiving fear of rape and voluntarily requesting mental health treatment in prison is unclear from the available data. Thus, we can only hypothesize the direction of the relationship between these findings. In addition, inmates self-reported their sexual orientation, their history of CSA, and whether they had requested mental health treatment. There are potential negative social consequences for male inmates reporting sensitive information while housed in correctional facilities (Kupers,2005; Warren et al., 2009). Men are less likely than women to characterize acts constituting sexual victimization in childhood or adulthood as sexual abuse or rape (Artime, McCallum, & Peterson, 2014). Therefore, it is possible that inmates underreported their endorsement of these survey questions.

Furthermore, as mentioned above, the measure of perceiving rape to be a big threat in prison did not directly measure inmates’ personally perceived threat of rape. Instead, general questions regarding perceptions of rape were asked (i.e., “Are people worried about rape?”). A better indicator would have been to ask an inmate whether he personally fears rape. Due to the secondary nature of this data, we were unable to account for personal fears. Research, however, suggests that people are likely to project their beliefs and attitudes onto others, such that if a person personally perceives rape to be a threat, he will assume that others do as well (Byrne & Blaylock, 1963; Gottfredson & Hirschi, 1990; Haynie & Osgood, 2005).

We did not directly test the relationship between fear of rape and adverse mental health consequences. Instead, we examined the impact of fear of rape on the likelihood to voluntarily seek mental health treatment while in prison. Thus, it is possible that inmates in this sample who perceive rape to be a big threat in prison do experience negative mental health outcomes but do not seek mental health treatment. It was also unclear from the data which inmates had been incarcerated in the adult system prior to age 18 and which inmates had entered the adult system at age 18. This distinction is important as PREA delineates specific guidelines to house inmates who are incarcerated in adult prisons prior to the age of 18 separately from adults.

This study utilized secondary analysis of publicly available data that coded survey responses from qualitative interviews. To create this data set, some detail from the original data was lost. Inmates, for example, were asked if they had voluntarily requested mental health treatment in prison (yes/no). Information was unavailable about inmates’ reasons for seeking treatment or the type of mental health treatment being sought (i.e., requesting medication or counseling). Some inmates may have requested treatment for concerns other than mental health, such as demonstrating initiative and rehabilitation to the parole board. Similarly, inmates who received mental health treatment in the community did not specify the type or amount of services. Participants in the current study were incarcerated men housed in general population, but it was unknown how many had psychiatric diagnoses and what those diagnoses were. Finally, data were unavailable about the prevalence of sexual victimization in the sample.

Directions for Future Research

This study adds to the literature on factors influencing inmates’ fear of rape in prison and their decision to voluntarily request mental health treatment. Additional research with diverse populations is warranted to better understand how inmates make the choice to request mental health treatment as mental health issues are prevalent among all justice-involved populations. Future studies in this area should examine mental health diagnoses, medication, detailed history of adverse childhood experiences, and availability of mental health services across multiple criminal justice settings. Male inmates were chosen as the population of interest since men make up the vast majority of the prison population in the United States (Carson, 2015) and have more violent means of sexual coercion than women in correctional settings (Beck et al., 2013). The dynamics of sexual victimization differ in female correctional facilities (Belknap, Lynch, & DeHart, 2015), warranting future research that examines female correctional samples.

The data for the current study were collected between 2004 and 2005, shortly following the passage of PREA. Since then, sexual violence in prison has received more attention from researchers and the public (e.g., Moster & Jeglic, 2009). Efforts from advocacy organizations, such as Just Detention International (2016), have increased awareness and rape prevention services in correctional facilities. Although shifting attitudes and awareness may affect inmates’ perceptions of rape and safety, the data from the current study are still relevant in better understanding the role of sexual orientation and CSA in inmates’ likelihood to request mental health treatment. Sexual minorities and inmates who have experienced CSA continue to be at increased risk of revictimization in prison. Given the length of time since the passage of PREA, however, more research is needed to examine inmates’ perceptions of safety and the threat of rape using current samples of diverse inmates. Despite limitations, the current study provides a foundation for examining male inmates’ perceptions of rape and mental health treatment–seeking behavior, with findings that have implications for practice and policy.

Footnotes

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) received no financial support for the research, authorship, and/or publication of this article.

Notes

Author Biographies

Mina Ratkalkar is a doctoral student in the clinical psychology program at Drexel University with a concentration in forensic psychology. She holds master’s degrees in social work and criminal justice. Her research interests include sexuality issues among justice-involved populations, gender-responsive interventions, and criminal and juvenile justice program evaluation. Currently, she provides mental health services for reentrants through the Federal Reentry Court in Philadelphia.

Cassandra A. Atkin-Plunk is an assistant professor in the School of Criminology and Criminal Justice at Florida Atlantic University. Her research interests span both institutional and community corrections with an emphasis on contemporary issues in corrections, including problem-solving courts and reentry and reintegration of offenders. Her research focuses on evidence-based practices and program evaluations to identify what works in corrections.

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