Abstract
Purpose:
Transgender and nonbinary (TNB) populations experience disproportionate rates of sexual assault. Despite evidence from cisgender samples linking sexual assault exposure to body image concerns and disordered eating behaviors, such as weight and shape control behaviors (WSCBs), little is known about these relationships in TNB people. The purpose of this study was to assess associations among past-year sexual assault exposure, body areas satisfaction, body weight esteem, and high-risk WSCBs in a sample of TNB young adults.
Methods:
A sample of 714 participants completed a cross-sectional online survey. Multivariable linear and logistic models were fit to determine associations between constructs of interest. Natural effects mediation analyses assessed for potential mediation of the relationship between sexual assault and WSCBs by body areas satisfaction and body weight esteem. Analyses were stratified by three gender identity categories.
Results:
Past-year sexual assault exposure was associated with significantly decreased body areas satisfaction, but only for nonbinary participants. No significant association was found between sexual assault and body weight esteem. Sexual assault was associated with significantly increased risk for WSCBs across gender identity categories. No mediation of these relationships by body areas satisfaction and body weight esteem was observed.
Conclusion:
Findings support clinical consideration of WSCBs in TNB survivors of sexual assault. Results suggest that multiple factors, including body image and sexual assault, may contribute separately to disordered eating behaviors in TNB young adults.
Keywords: body image, dehumanization, disordered eating, nonbinary, sexual violence, transgender
Introduction
Transgender and nonbinary (TNB) people are over four times more likely than cisgender people to experience violent crimes, including sexual assault.1,2 Prevalence estimates for lifetime sexual assault have ranged from 47% to 64% in large community samples of TNB adults.3,4 Despite calls for a public health response to sexual assault centering the unique needs of TNB survivors,5 research with TNB populations has yet to explore the relationship between sexual assault and two key areas of psychological well-being: body image and disordered eating.
Disordered eating often involves high-risk weight and shape control behaviors (WSCBs; e.g., fasting, vomiting, diet pill use), driven by a motivation to change or maintain a particular body presentation.6,7 Accordingly, body image concerns are central cognitive components of these behaviors and their harmful health outcomes.7,8 Binge eating, while not necessarily a product of weight and shape control motivations, is often conceptualized in association with WSCBs due to high diagnostic crossover among eating disorders and related behaviors.9,10 Given that these behaviors are associated with severe psychological distress and potentially life-threatening biomedical consequences,11–14 understanding their associated risk factors for TNB people is critically important.
In cisgender samples, sexual assault is associated with poorer body evaluations15 and body esteem,16 as well as increased body dissatisfaction,17 body shame,18 and eating disorder symptoms.19–21 Objectification theory (i.e., a sociocultural context that sexually objectifies and reduces a person to their physical appearance generates psychological distress)22 has been applied to understand these deleterious outcomes.18,23 From this perspective, sexual assault engenders self-objectification, which can heighten body image concerns24; people may respond to these concerns by trying to change their appearance through WSCBs.23,25
Consistent with objectification theory, evidence has accumulated for strong relationships between body image concerns and disordered eating,26 suggesting a pathway from sexual assault to disordered eating through body image concerns.21 One series of studies has examined this pathway among cisgender people, indicating that body shame may mediate the relationship between sexual assault and disordered eating.23,24 However, the contributions of other body image components (e.g., body areas satisfaction, body esteem) remain unexplored.
Body image and disordered eating warrant particular attention, given the disproportionate burden of disordered eating in TNB young people relative to cisgender people.27–31 To explain these inequities, the pantheoretical dehumanization model32–34 unites objectification theory with minority stress theory (i.e., stigma and discrimination due to one's marginalized identity status generate health inequities).35,36 This model proposes that internalizing dehumanizing experiences (e.g., discrimination, objectification) and anticipating future experiences cause cognitive, affective, and physiological responses that confer adverse mental and behavioral health outcomes. For example, research within this model has linked continuous experiences of verbal harassment and discrimination to negative body image and disordered eating in TNB populations through internalization of sociocultural standards of attractiveness.32,34 Sexual assault has been conceptualized as a universally dehumanizing experience,33,37 which may be compounded by the interplay of minority stress and objectification for TNB people to exacerbate adverse outcomes.
In understanding the impact of sexual assault on TNB people, it is important to consider potential differences across gender. Compared to transgender men and women, nonbinary people report higher body satisfaction,30,38 but heightened eating disorder symptoms.39 Research suggests that transgender women tend to prioritize thinness, while transgender men tend to prioritize muscularity,7,40,41 potentially producing differing body image concerns and WSCBs. However, it remains unknown whether associations between sexual assault, body image, and WSCBs vary by gender identity.
Young adulthood is a period of heightened risk for sexual assault.42 Furthermore, both negative body image43 and disordered eating behaviors commonly manifest in late adolescence or early adulthood.44,45 Thus, young adulthood represents a key period for research addressing sexual assault, body image, and WSCBs.
This study therefore aimed to examine relationships between sexual assault exposure and body image, binge eating, and high-risk WSCBs among TNB young adults. We predicted that past-year sexual assault would be negatively associated with body weight esteem and body areas satisfaction. We further hypothesized that sexual assault would be associated with higher odds of high-risk WSCBs and binge eating. Finally, we tested a cross-sectional mediation model in which body areas satisfaction and body weight esteem mediate the relationship between sexual assault exposure and WSCBs. As an exploratory aim, we stratified analyses by gender identity to examine potential gender differences.
Materials and Methods
Participants and procedures
This analysis used cross-sectional online survey data collected as part of the Body Image, Sexual Health, and Relationships Project (B*SHARP), a mixed-methods research project examining structural and interpersonal determinants of sexual health. Participants were recruited using social media advertisements (i.e., Facebook and Instagram) and online outreach through regional lesbian, gay, bisexual, transgender, and queer (LGBTQ+) organizations, U.S. campus LGBTQ+ groups, and trans-specific groups on Facebook and Reddit. Data were collected from February to July, 2019. Eligibility criteria for this study included the following: (1) identification with a gender different than that assigned at birth (e.g., TNB); (2) age 18–30 years; (3) U.S. residence; and (4) proficiency in English.
Eligible participants received an email link to provide informed consent and then complete an anonymous online questionnaire on psychosocial wellbeing, identity, health, and romantic relationships. Participants could choose to receive a $10 e-gift card or donate $10 to a transgender health and human rights organization. Of 1677 complete survey responses, 298 were excluded through automated procedures (e.g., incorrect responses to two attention check questions, highly similar email addresses) and 665 were excluded through manual procedures (e.g., different answers to questions asked twice, duplicative free text responses); most excluded responses had similarities that suggested they originated from duplicate users. All procedures were approved by the Institutional Review Board of Boston Children's Hospital.
Measures
Gender identity
Participants were asked to select the gender identity label that best described them from 16 options (e.g., agender, genderqueer, trans female) along with a write-in option. Gender identity categories were collapsed into trans men, trans women, and nonbinary people to assess differences between binary and nonbinary gender identities.
Past-year sexual assault exposure
Participants responded yes or no to past-year experiences of sexual assault in four categories: force or threat of physical force; incapacitation due to drugs/alcohol/sleep; coercion through serious nonphysical harm or promised rewards; and failure to obtain consent. Participants reported each experience in relation to either oral/penetrative assault or kissing/other sexual touching; an additional item assessed attempted physical force for a total of nine items. A binary composite variable was created for any past-year sexual assault exposure.
Outcome measures
Body areas satisfaction
Body areas satisfaction was measured using the 10-item Body Areas Satisfaction Subscale of the Multidimensional Body-Self Relations Questionnaire.46 Participants indicated how satisfied they felt with areas or aspects of their body (e.g., face, muscle tone, overall appearance; 1 = very dissatisfied and 5 = very satisfied). Cronbach's alpha for this measure was 0.82 for transgender women, 0.81 for transgender men, and 0.78 for nonbinary participants, indicating acceptable-to-good internal consistency.
Body weight esteem
Body weight esteem was assessed by calculating mean scores of the Body-Esteem Scale for Adolescents and Adults—Weight Subscale.47 This 7-item measure asks participants to rate their agreement with items such as “my weight makes me unhappy” (1 = never and 5 = always). Cronbach's alpha for this measure was 0.92 for women, 0.90 for men, and 0.90 for nonbinary participants, indicating excellent internal consistency.
Past-year high-risk weight and shape control behaviors
Participants reported frequency of past-year engagement in high-risk WSCBs (including fasting, vomiting, laxative use, and diet pill use; 1 = never and 5 = more than once a week), with questions adapted from the Youth Risk Behavior Surveillance System questionnaire.48,49 Questions were framed from a weight-loss/maintenance perspective (“How often did you do any of the following to try to lose weight or keep from gaining weight”). Following methods used previously,50 a binary composite variable for WSCBs was constructed (1 = any past-year behavior and 0 = no past-year behavior).
Binge eating
Participants reported frequency of past-year eating binges (1 = never and 5 = more than once a week) and whether they experienced loss of control during eating binges.51 A binary composite variable for binge eating was constructed following scoring guidelines used in past studies52 (1 = any past-year binge with loss of control and 0 = no past-year binge or no loss of control).
Covariate measures
Childhood sexual abuse
Experience of childhood sexual abuse was measured using the sexual abuse items of the Adverse Childhood Experiences scale.53 Participants answered yes or no to four questions assessing sexual abuse (e.g., “did an adult or person at least 5 years older touch or fondle you in a sexual way?”). A binary composite variable was created for any childhood sexual abuse.
External perception as cisgender
Being perceived as cisgender was assessed by a single-item measure drawn from the 2015 U.S Transgender Survey: “People can tell if I'm trans, even if I don't tell them” (1 = always and 5 = never).4
Data analysis
Descriptive statistics and hypothesis testing analyses were conducted using R 4.0.1.54 Missing values were multiply imputed using the “mice” 3.14.4 package in R.55 Five hundred imputations were run using all model variables in the predictor matrix. Missingness was <3% for all variables.
Given documented associations with constructs of interest, models were adjusted for childhood sexual abuse,56,57 perceived visual gender conformity,58,59 and race/ethnicity.1,60 To assess for gender differences, all analyses were stratified by three gender identity categories.
Multivariable linear models were constructed for the association of sexual assault exposure with body weight esteem and body areas satisfaction. Multivariable logistic models were constructed for the associations of sexual assault exposure and body image concerns with WCSBs and binge eating. Natural effects mediation analysis using the “medflex” 0.6.7 package in R61 assessed the extent to which body image concerns could mediate relationships between sexual assault exposure and WSCBs. Given the strong correlation (r = 0.69, p < 0.001) and conceptual similarity between body weight esteem and body areas satisfaction, these variables were treated as potential joint mediators. As preliminary logistic modeling between sexual assault exposure and binge eating showed no significant association, mediation analyses were not performed for this outcome.
Results
Participant characteristics
Pre-imputation descriptive statistics for sociodemographic characteristics and prevalence of sexual assault and WSCBs, stratified by gender identity, are presented in Table 1.62 The final sample consisted of 714 participants (mean = 23.8 years old and standard deviation = 3.27), of whom 259 identified as trans women (36.3%), 141 as trans men (19.7%), and 314 as nonbinary people (44.0%). Overall, less than half of the sample (43.8%) identified as monoracial White, followed in frequency by multiracial/multiple races or ethnicities (24.1%). Most participants reported a sexual minority identity (90.3%).
Table 1.
Sociodemographic Characteristics of the Sample and Prevalence of Past-Year Sexual Assault Exposure and Past-Year High-Risk Weight and Shape Control Behaviors by Gender Identity
| Gender identitya | Trans women (n = 259), n (%) | Trans men (n = 141), n (%) | Nonbinary people (n = 314), n (%) |
|---|---|---|---|
| Age | |||
| M | 24.2 | 24.3 | 23.6 |
| SD | 2.96 | 3.03 | 3.39 |
| Race/ethnicityb | |||
| American Indian | 2 (0.8) | 2 (1.4) | 3 (1.0) |
| Asian | 8 (3.1) | 12 (8.5) | 29 (9.2) |
| Black | 32 (12.4) | 17 (12.1) | 47 (15.0) |
| Latinx | 19 (7.3) | 21 (14.9) | 30 (9.6) |
| Middle Eastern | 1 (0.4) | 0 (0.0) | 4 (1.3) |
| Multiracial or multiple races | 32 (12.4) | 35 (24.8) | 106 (33.8) |
| Pacific Islander | 1 (0.4) | 0 (0.0) | 0 (0.0) |
| White | 164 (63.3) | 54 (38.3) | 95 (30.3) |
| Sexual orientation | |||
| Asexual | 3 (1.2) | 6 (4.3) | 30 (9.6) |
| Bisexual | 58 (22.4) | 27 (19.1) | 47 (15.1) |
| Gay | 29 (11.2) | 18 (12.8) | 17 (5.4) |
| Lesbian | 44 (17.0) | 4 (2.8) | 19 (6.1) |
| Pansexual | 39 (15.1) | 22 (15.6) | 61 (19.6) |
| Queer | 25 (9.7) | 37 (26.2) | 118 (37.8) |
| Questioning | 11 (4.2) | 3 (2.1) | 5 (1.6) |
| Straight | 44 (17.0) | 23 (16.3) | 2 (0.6) |
| Other | 6 (2.3) | 1 (0.7) | 13 (4.2) |
| Regionc | |||
| Midwest | 42 (16.2) | 20 (14.2) | 45 (14.3) |
| Northeast | 69 (26.6) | 46 (32.6) | 128 (40.8) |
| South | 69 (26.6) | 39 (27.7) | 80 (25.5) |
| West | 79 (30.5) | 36 (25.5) | 61 (19.4) |
| Education degree | |||
| Some high school | 1 (1.3) | 0 (0.0) | 3 (1.5) |
| High school diploma or GEDd | 28 (35.0) | 7 (22.6) | 17 (8.5) |
| Some college | 28 (35.0) | 13 (41.9) | 80 (40.0) |
| College diploma | 19 (23.8) | 11 (35.5) | 87 (43.5) |
| Graduate degree | 4 (5.0) | 0 (0.0) | 23 (11.5) |
| Past-year hunger due to financial straine | |||
| Never | 174 (67.2) | 101 (71.6) | 200 (63.7) |
| Only 1 or 2 months | 51 (19.7) | 18 (12.8) | 39 (12.4) |
| Some months, but not every month | 27 (10.4) | 16 (11.3) | 40 (12.7) |
| Almost every month | 7 (2.7) | 6 (4.3) | 35 (11.1) |
| Sex assigned at birth | |||
| Male | 259 (100) | 0 (0.0) | 44 (14.0) |
| Female | 0 (0.0) | 141 (100) | 270 (86.0) |
| Past-year sexual assault exposure | |||
| Yes | 80 (31.1) | 31 (22.3) | 114 (36.3) |
| No | 177 (68.9) | 108 (77.7 | 200 (63.7) |
| Past-year high-risk weight and shape control behaviorsf | |||
| Fasting | 118 (45.7) | 56 (39.7) | 132 (42.0) |
| Vomiting | 59 (22.9) | 19 (13.5) | 45 (14.4) |
| Laxative use | 49 (18.9) | 8 (5.7) | 21 (6.7) |
| Diet pill use | 43 (16.7) | 9 (6.4) | 18 (5.8) |
| Binge eating | 73 (28.6) | 39 (28.1) | 110 (35.3) |
Totals for each category may not add up to respective sample sizes due to missing data.
Participants who selected more than one race/ethnicity category or who self-identified as multiracial were grouped for comparisons.
Regions were constructed using U.S. Census Bureau divisions.62
General Educational Development test.
Participants were asked, “How often during the past 12 months have you been hungry because you could not afford more food?”
As many participants reported more than one behavior, column totals are above respective sample sizes.
GED, General Educational Development; M, mean; SD, standard deviation.
Table 2 displays the prevalence of past-year WSCBs by gender identity and past-year sexual assault exposure. Notably, 42.9% of participants reported any past-year fasting behavior, and 31.4% reported any past-year binge eating behavior. Chi-square tests revealed significant differences in past-year WSCBs by sexual assault: transgender women and nonbinary participants who reported sexual assault were more likely to report any WSCB compared to those who did not report sexual assault, within respective gender categories. No significant difference was observed for transgender men.
Table 2.
Reports of Past-Year High-Risk Weight and Shape Control Behaviors by Gender Identity and Past-Year Sexual Assault Exposure
| Gender identity |
Trans women (n = 259), n (%) |
χ2, p | Trans men (n = 141), n (%) |
χ2, p | Nonbinary people (n = 314), n (%) |
χ2, p | |||
|---|---|---|---|---|---|---|---|---|---|
| Sexual assault exposure | Yes (n = 80) | No (n = 177) | Yes (n = 31) | No (n = 108) | Yes (n = 114) | No (n = 200) | |||
| Past-year high-risk weight and shape control behaviors | 60 (75.0) | 82 (46.3) | 4.44, p = 0.035* | 20 (64.5) | 51 (48.6) | 1.84, p = 0.175 | 65 (57.5) | 82 (41.2) | 7.06, p = 0.008** |
| Past-year binge eating | 29 (36.7) | 44 (25.3) | 2.98, p = 0.084 | 9 (29.0) | 30 (28.3) | 0.00, p = 1.00 | 46 (41.1) | 64 (32.0) | 1.87, p = 0.171 |
Statistically significant at p < 0.05.
Statistically significant at p < 0.01.
Sexual assault exposure as a predictor of body image concerns
Table 3 presents estimates from adjusted multivariable linear models of associations between past-year sexual assault exposure and body image concerns (body weight esteem and body areas satisfaction). Sexual assault was not associated with significant differences in body weight esteem across gender identities. However, associations were all in the expected direction. Sexual assault was associated with significantly lower levels of body areas satisfaction among nonbinary participants only (ß = −0.15, 95% confidence interval [CI]: −0.29 to 0.00, p = 0.047).
Table 3.
Results from Multivariable Linear and Logistic Regression Analyses of the Relationship between Past-Year Sexual Assault Exposure and Body Image Measures, Past-Year High-Risk Weight and Shape Control Behaviors, and Past-Year Binge Eating, Stratified by Gender Identity
| Body weight esteem |
Body areas satisfaction |
High-risk weight and shape control behaviors |
Binge eating |
|||||
|---|---|---|---|---|---|---|---|---|
| ß (95% CI) | p | ß (95% CI) | p | AOR (95% CI) | p | AOR (95% CI) | p | |
| Trans women | −0.13 (−0.42 to 0.16) | 0.372 | −0.09 (−0.30 to 0.12) | 0.405 | 2.41 (1.23 to 4.72) | 0.010* | 1.47 (0.75 to 2.86) | 0.260 |
| Trans men | −0.03 (−0.42 to 0.35) | 0.863 | −0.03 (−0.30 to 0.23) | 0.812 | 2.73 (1.03 to 7.20) | 0.045* | 0.97 (0.36 to 2.57) | 0.947 |
| Nonbinary people | −0.14 (−0.33 to 0.06) | 0.182 | −0.15 (−0.29 to 0.00) | 0.047* | 1.82 (1.13 to 2.96) | 0.015* | 1.37 (0.83 to 2.24) | 0.218 |
Statistically significant at p < 0.05.
All models were adjusted for childhood sexual abuse, perceived visual gender conformity, and race/ethnicity.
AOR, adjusted odds ratio; CI, confidence interval.
Sexual assault exposure as a predictor of high-risk WSCBs and binge eating
Table 3 illustrates the results of adjusted multivariable logistic models predicting past-year high-risk WSCBs and past-year binge eating by past-year sexual assault exposure. Sexual assault exposure was associated with significantly higher odds of WSCBs for all gender categories. However, sexual assault did not significantly predict binge eating across gender categories.
Body image concerns as predictors of high-risk WSCBs and binge eating
Adjusted multivariable logistic models of relationships between body image concerns and disordered eating outcomes revealed robust relationships across gender identities—both body areas satisfaction and body weight esteem were significantly associated with higher odds of past-year high-risk WSCBs and past-year binge eating (Table 4).
Table 4.
Results from Multivariable Logistic Modeling of the Relationships between Past-Year High Risk Weight and Shape Control Behaviors and Binge Eating and Body Image Measures, Stratified by Gender Identity
| High-risk weight and shape control behaviors |
Binge eating |
|||||||
|---|---|---|---|---|---|---|---|---|
| Body weight esteem |
Body areas satisfaction |
Body weight esteem |
Body areas satisfaction |
|||||
| AOR (95% CI) | p | AOR (95% CI) | p | AOR (95% CI) | p | AOR (95% CI) | p | |
| Trans women | 0.48 (0.35 to 0.66) | <0.001*** | 0.57 (0.38 to 0.86) | 0.008** | 0.29 (0.20 to 0.44) | <0.001*** | 0.40 (0.25 to 0.64) | <0.001*** |
| Trans men | 0.30 (0.18 to 0.50) | <0.001*** | 0.23 (0.11 to 0.47) | <0.001*** | 0.15 (0.07 to 0.31) | <0.001*** | 0.18 (0.08 to 0.41) | <0.001*** |
| Nonbinary people | 0.31 (0.22 to 0.44) | <0.001*** | 0.30 (0.20 to 0.47) | <0.001*** | 0.37 (0.26 to 0.52) | <0.001*** | 0.49 (0.32 to 0.73) | <0.001*** |
Statistically significant at p < 0.01.
Statistically significant at p < 0.001.
All models were adjusted for childhood sexual abuse, perceived visual gender conformity, and race/ethnicity.
Body image concerns as mediators of the association between sexual assault exposure and high-risk WSCBs
As displayed in Table 5, natural effects mediation analysis indicated no significant indirect effect of sexual assault exposure on WSCBs by body image, although indirect effect point estimates were in the expected direction for all gender categories. Direct effects of sexual assault exposure on WSCBs were significant across gender categories.
Table 5.
Estimates of Natural Direct and Indirect Effects As Well As Total Effects of Past-Year Sexual Assault Exposure on Past-Year High-Risk Weight and Shape Control Behaviors As Mediated By Body Weight Esteem and Body Areas Satisfaction Joint Mediators, Stratified By Gender Identity
| Natural direct effect |
Natural indirect effect |
Total effect |
||||
|---|---|---|---|---|---|---|
| AOR (95% CI) | p | AOR (95% CI) | p | AOR (95% CI) | p | |
| Trans women | 2.12 (1.15 to 3.92) | 0.016* | 1.11 (0.89 to 1.38) | 0.374 | 2.39 (1.22 to 4.68) | 0.011* |
| Trans men | 2.76 (1.11 to 6.84) | 0.028* | 1.03 (0.66 to 1.63) | 0.883 | 2.79 (1.04 to 7.50) | 0.042* |
| Nonbinary people | 1.55 (1.01 to 2.41) | 0.046* | 1.17 (0.95 to 1.44) | 0.135 | 1.83 (1.13 to 2.96) | 0.014* |
Statistically significant at p < 0.05.
All models were adjusted for childhood sexual abuse, perceived visual gender conformity, and race/ethnicity.
Variation among subgroups of nonbinary participants
Post-hoc analyses stratified the nonbinary subsample by sex assigned at birth (SAB) to examine differences in associations between participants assigned female at birth (AFAB; n = 270) and assigned male at birth (AMAB; n = 44). Results (Supplementary Table S1) illustrated similar point estimates for associations between sexual assault exposure and body image concerns for AFAB and AMAB participants. For AFAB participants, adjusted odds ratios (AORs) for the significant association between sexual assault and high-risk WSCBs and the relationship between sexual assault and binge eating were in expected directions. However, AORs were in the opposite direction for AMAB participants for both WSCBs (AOR = 0.65, 95% CI: 0.15 to 2.92, p = 0.580) and binge eating (AOR = 0.61, 95% CI: 0.12 to 3.04, p = 0.548).
Discussion
TNB people report past experiences of violent victimization at alarming rates. This study found that TNB people who reported past-year sexual assault were more likely to report past-year high-risk WSCBs. Results highlight a need for further research to investigate mechanisms underlying this relationship, and encourage clinicians to account for this under-considered pathway in treatment.
Disordered eating among TNB individuals is often considered a response to body dissatisfaction fueled by gender dysphoria (e.g., to suppress secondary sex characteristics or feel closer to a gender-congruent body ideal).28,63,64 Indeed, past research has demonstrated that gender-affirming medical interventions can ameliorate body image concerns and disordered eating symptoms.29,65 Accordingly, relationships between body image concerns and WSCBs as well as binge eating were observed in this sample.
However, this study also found an association between sexual assault and WSCBs which was not mediated by body image concerns. This suggests multiple pathways, involving both universal factors and gender modality-specific concerns, by which TNB people come to engage in high-risk WSCBs.64,66 Results imply that WSCBs associated with sexual assault may develop through other psychological mechanisms, such as need for control or emotion dysregulation.21 Future research should explore these alternative mechanisms to better understand how sexual assault and WSCBs interact for TNB people.
Linear models also revealed a significant negative association between sexual assault exposure and body areas satisfaction for nonbinary participants, consistent with findings in cisgender samples.17 This significant association was observed independently from the association between sexual assault and WSCBs, suggesting that each might appear in different groups of nonbinary people based on additional factors (e.g., body ideals).67 Alternatively, this effect may reflect the larger sample size of nonbinary participants relative to other gender categories. The association between sexual assault and body areas satisfaction had a similar effect size (ß = −0.09, 95% CI: −0.30 to 0.12) for trans women as for nonbinary participants. Thus, future studies with larger samples for each gender category might clarify whether this relationship is unique to nonbinary people or, alternatively, is uniquely absent among trans men.
Post-hoc models for nonbinary participants stratified by SAB revealed similar effect sizes for body image concerns, supporting aggregation. Associations between sexual assault and high-risk WSCBs and binge eating suggest the possibility of distinctive processes for AMAB nonbinary participants, with point estimates in the reverse of expected directions. Yet, these associations were not significant and could have been an artifact of the small AMAB subsample (n = 44). Future research with larger samples can examine potential variation across nonbinary populations.
This study prompts an array of clinical considerations to support TNB survivors of sexual assault. The observed relationship between sexual assault and WSCBs supports the need for a sexual assault response that addresses the physiological and psychological outcomes of sexual assault experiences together.5,68 Providers should also not assume that gender congruence or gender confirmation motivates WSCBs, but rather consider the breadth of associated factors that may contribute. Finally, mental health clinicians might explore the complex relationships between sexual assault, body satisfaction, and WSCBs among nonbinary patients.
Limitations
These findings can be best understood in light of methodological limitations that prompt further study. Because this study used cross-sectional data, results may have been biased by reverse causation. For instance, while we propose that sexual assault victimization may negatively influence WSCBs, this association could occur in a different sequence. To better understand how sexual assault generates adverse health outcomes, further research should employ longitudinal assessment of body image concerns and WSCBs as a function of sexual assault incidence.
Findings are also limited by sample size constraints, which may have affected the power to detect associations, such as that between sexual assault and body areas satisfaction, across gender categories. Furthermore, this study could not separate out specific nonbinary identity labels (e.g., gender fluid, agender) due to small subsample sizes, limiting the interpretation of gender differences. Nonetheless, by illuminating preliminary distinctions between nonbinary and binary transgender populations in sexual assault associations, this study paves the way for research with larger samples to better understand variations in sexual assault outcomes across gender identities.
Conclusions
In demonstrating an association between past-year sexual assault exposure and body areas satisfaction for nonbinary people, this study calls for further public health focus on risk factors for negative body image in this understudied population. Results illustrated that sexual assault is associated with increased odds of high-risk WSCBs among TNB young adults, urging attention to this relationship in clinical environments. The finding that body image concerns do not play a role in this relationship suggests recognition of the complex and diverse risk factors that can lead TNB people to adverse behavioral outcomes.
Supplementary Material
Acknowledgments
We would like to thank all the B*SHARP participants for their time, honesty, and dedication!
Authors' Contributions
All authors conceptualized and designed the study. B.E.E. conducted data analyses and drafted the article. G.R.M., Z.A.S., and A.R.G. contributed significantly to data interpretation and article revisions. All authors reviewed and approved the final version of the article before submission and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy and integrity of the work are appropriately investigated and resolved.
Author Disclosure Statement
The authors have no conflicts of interest to disclose.
Funding Information
The Body Image, Sexual Health and Relationships Project (B*SHARP) was funded by the Aerosmith Endowment Fund for the Prevention and Treatment of HIV and Other Sexually Transmitted Infections; Harvard University Open Gate Foundation; and the Research Education Institute for Diverse Scholars (REIDS) pilot grant from National Institute of Mental Health grant 1R25GM111837-01. Research and authorship for B.E.E. were funded by the David R. Kessler MD’55 Fund for LGBTQ Mental Health Research at Yale.
Supplementary Material
References
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