Sexual Victimization Among Sexual and Gender Minoritized Groups: Recent Research and Future Directions

Abstract

Purpose of the review:

Sexual victimization is a significant public health concern. Compared to heterosexual and cisgender peers, sexual and gender minoritized (SGM) individuals are at elevated risk for sexual victimization. Prominent theories suggest that this risk is due in part to the stigma SGM individuals face when navigating heteronormative cultures. The goal of this article is to review the prevalence, risk factors, and consequences of sexual victimization in SGM individuals.

Recent findings:

Studies continue to show that SGM individuals—bisexual and/or gender minoritized in particular—are at higher risk for sexual victimization. Little work has focused on risk factors, though recent research continues to highlight post-victimization disparities among SGM individuals. Emerging studies also point to theoretically informed factors that may influence victimization risk and recovery, including sexual and gender-related stigma.

Summary:

To inform prevention and intervention efforts, future research would benefit from streamlining assessment, methodology, and dissemination practices.

Introduction

Sexual victimization is a pervasive problem worldwide. In the US, upwards of 18.3% of women and 1.4% of men have experienced rape in their lifetime (1). Moreover, 44.6% of women and 22.2% of men report sexual victimization other than rape (1). Specific groups, such as those identifying as sexual and gender minoritized (SGM), are at particularly high risk for sexual victimization (2, 3). The negative impact of victimization on subsequent mental and physical health outcomes has been well documented (4), including among SGM individuals (5)^••. Drawing on our knowledge of the research literature, with a focus on quantitative studies published from the US and Canada in the past year (2021–2022), we review the prevalence, risk factors, and consequences of sexual victimization in SGM individuals. When possible, we highlight studies examining differences between SGM and other groups (e.g., heterosexual and/or cisgender), but also within SGM sub-groups (e.g., gay versus bisexual). Recommendations for future research will also be discussed.

Operationalizing Sexual and Gender Identity

According to a 2020 Gallup poll, 5.6% of US adults self-identify as lesbian, gay, bisexual, and/or transgender (6). Sexual and gender identity are fluid constructs that evolve over an individual’s lifetime amidst an ever-shifting cultural backdrop (7, 8). Given the challenges of defining the complexities of human experiences, standard definitions are necessary to provide a foundation for this review.

Sexual orientation is a multidimensional construct that includes sexual attraction, sexual behavior, and sexual identity. Terms like lesbian, gay, bisexual, queer, and heterosexual are frequently used to refer to sexual identity but also can describe sexual attraction and/or behavior. Attraction and behavior, however, do not always align with how someone identifies. For example, during adolescence, sexual attraction is a prominent element of sexual orientation as many may not yet know or want to label their sexual identity, let alone disclose it to others (9). Sexual orientation is fluid across the lifespan (10, 11) and, particularly in the case of identity and behavior, may vary by social context (e.g., home, school, work).

Gender identity is an individual’s psychological sense of their gender (12) and is distinct from sexual orientation. Cisgender refers to someone for whom their sex assigned at birth aligns with their gender identity. Transgender is a broad term that captures the experiences of those whose assigned sex does not align with how they identify. Moreover, there are a variety of other terms used by individuals for whom the categories of male/female fail to capture how they see themselves, such as agender, genderqueer, gender fluid, gender non-conforming, and non-binary (13). Gender expression, on the other hand, involves how an individual communicates their gender identity to others via their appearance, clothing, or mannerisms (14).

Sexual and gender minoritized (SGM) is used to represent a vast array of identities and experiences under a single population label (15). When necessary, in this article, we use sexual minoritized in reference to individuals who endorse a sexual orientation other than heterosexual (e.g., lesbian, gay, bisexual) and gender minoritized in reference to individuals (regardless of sexual orientation) who endorse a gender identity that does not align with their sex assigned at birth (e.g., transgender, genderqueer, non-binary).

Theoretical Frameworks for Sexual Stigma and Minority Stress

In 2016, SGM individuals were designated as a health disparity population by the National Institutes of Health in recognition that this group disproportionally suffers from worse mental and physical health outcomes relative to heterosexual and cisgender peers. Notably, these disparities are often exacerbated in SGM individuals who have experienced sexual victimization (16–18)^•. This risk, both for sexual victimization and worse post-victimization outcomes, may be attributable, at least in part, to the stigma SGM individuals face when navigating a heteronormative culture.

Sexual stigma and gender minority stigma reflect the negative regard that society directs toward non-heterosexual and non-gender-conforming experiences, identities, and communities (19, 20). These stigmas are fundamentally rooted in systems that privilege heterosexual and cisgender individuals (19), resulting in a culture of pervasive heteronormativity, which assumes everyone is heterosexual and other sexual identities are inferior, and gender binarism, which assumes that gender only exists as a male/female binary and thus stigmatizes those who do not conform (20). These ways of thinking are ingrained in social norms, institutions, and laws, resulting in pervasive implicit and explicit culturally stigmatizing messages that SGM individuals are not only lower on the social ladder, but also justifiable targets for violence.

Societal-level manifestations of stigma affect SGM individuals in three main ways (19). First, enacted stigma is the direct experience of discrimination or victimization as a result of sexual and/or gender identity. Second, even in the absence of enacted stigma, SGM individuals can be affected by felt stigma, which refers to the constant worry that one will be victimized or discriminated against because of their identities. Third, internalized stigma refers to SGM individuals’ acceptance of societal-level stigma into their own self-concept (i.e., internalized heterosexism). Minority stress theory (21–23) posits that the chronic stress SGM individuals experience from these stigmas perpetuate health disparities. Thus, minority stress can influence cognitive, affective, and interpersonal processes to “get under the skin” and adversely impact the mental and physical health of those chronically exposed (24). Awareness of this vulnerability is a critical prerequisite to understanding sexual victimization risk in SGM individuals as well as factors that may promote or inhibit post-victimization recovery.

Sexual Victimization Among Sexual and Gender Minoritized Groups

Sexual victimization includes a wide range of nonconsensual sexual experiences including unwanted contact, attempted rape, and completed rape (25). At any level of severity, perpetrators can use a variety of tactics including threats, physical force, incapacitation from alcohol or other drugs, or not giving one a chance to say “no” (26). Although sexual victimization research has historically focused on rape, it is critical to consider the full range of severity, as lower severity incidents like sexual harassment and touching are highly prevalent and more commonly endorsed than rape (27, 28). Moreover, lower severity victimization can serve as a form of ‘boundary testing’ and has the potential to escalate into more severe forms of victimization (29).

Compared to heterosexual and cisgender peers, SGM individuals report higher rates of sexual victimization. In a systematic review of 75 studies, Rothman et al. (2011) found that 43% of sexual minoritized women and 30% of sexual minoritized men experience sexual victimization in their lifetime (2). Across individual studies, prevalence rates tend to vary widely (e.g., 16–85% of sexual minoritized women, 12–54% of sexual minoritized men) (2). This variability is likely due to heterogeneity in recruitment methods (e.g., convenience samples versus nationally representative samples) as well as the methods for assessing sexual victimization (e.g., single item versus behaviorally-specific sets of items). Recently published prevalence rates continue to underscore sexual victimization disparities for SGM individuals (30, 31, 32)^•, while also showing greater severity of victimization in this population (32)^•. In a national college sample, SGM students were more likely to have ever experienced sexual victimization (30.8% of sexual minoritized students, 45% of gender minoritized students) compared to students identifying as heterosexual (18.5%) or cisgender (19.6%), respectively (33)^•. An emerging body of research has also identified heightened risk in sub-groups of SGM individuals. For instance, Grocott et al. (2021) found that gender minoritized students were nearly 9 times more likely to have experienced sexual victimization than cisgender students. In a national, non-probability sample, 80.1% of bisexual women and 62.7% of lesbian women reported a sexual victimization history relative to 44.4% of heterosexual women (34)^•. Consistent with the larger literature (35)^•, Canan et al. (2021) showed that bisexual women in particular reported higher rates than both lesbian and heterosexual women, though lesbian women also were at elevated risk compared to heterosexual peers (34)^•. These studies underscore the importance of not only exploring differences between groups, but also within SGM populations, to help identify who might be especially at risk.

Sexual Victimization Correlates

A rigorous body of research has identified factors that heighten vulnerability for sexual victimization among (presumably) heterosexual women, including a history of childhood sexual abuse (36, 37), hazardous alcohol use (38), and sexual risk behaviors (39). These factors have also been found to predict sexual victimization among SGM individuals (40, 41, 42)^• and are consistent with minority stress theory (21–23) and a self-medication framework (43), which would posit that SGM individuals may be more likely to cope with chronic minority stress via alcohol or sex. Over time, these short-term self-regulatory attempts can reinforce and maintain maladaptive coping, but also inadvertently increase risk for sexual revictimization.

Importantly, and in alignment with minority stress theory, emergent studies suggest that sexual and gender identity-related stigma directly impact victimization experiences. For example, consistent with a stigma-based framework, the association between being a transgender person of color and sexual victimization severity was stronger for those with greater trans visibility (i.e., “people can tell I am transgender even if I don’t tell them”) (44)^•. Other recent research has more directly considered the impact of minority stress on sexual victimization risk, particularly among bisexual identified individuals, as this sub-group is at greater risk relative to both heterosexual and other sexual minoritized peers (35)^•. For instance, bisexual women who experienced biphobia and hostile sexism in their social circles were more likely to report sexual victimization in the past year (45)^•. Relatedly, sexual stigma was found to predict sexual victimization for bisexual SGM individuals, and to a lesser degree, lesbian SGM individuals (46)^•. Notably, much of the literature on sexual victimization prevalence and correlates, including recent research, has relied on cross-sectional designs. Certainly, more longitudinal studies are needed to understand the shared and unique risk factors that make SGM individuals - including specific sub-groups - more vulnerable to sexual victimization.

The Sequelae of Sexual Victimization

Within the larger literature, sexual victimization in (presumably) heterosexual populations has been associated with a host of mental health consequences, including depression, anxiety, posttraumatic stress, disordered eating, and substance use disorders (4). These associations also hold true for SGM individuals. For example, among sexual minoritized cisgender women, those who experienced rape in adulthood reported more mental health symptoms and more hazardous drinking than their non-victimized peers (16)^•. Holmes et al. (2021) found a significant association between sexual victimization and disordered eating among bisexual cisgender women (47)^•. Similarly, a secondary analysis of 27,795 US transgender individuals indicated that past-year unwanted sexual contact was associated with increased risk for suicidal ideation (48)^•. Sexual victimization is also associated with negative physical health outcomes. For instance, sexual minoritized cisgender women who were sexually revictimized were at increased risk for binge eating, obesity, and hypertension (49)^•.

The reviewed literature suggests that both SGM identity and sexual victimization history confer independent risk for negative mental health, substance use, and physical health outcomes. Fewer studies, however, have explored how the link between sexual victimization and post-victimization consequences vary as a function of SGM identity. Theory (21, 22, 24) posits that the chronic stress associated with SGM identities “gets under the skin” to contribute to mental health disparities, and for SGM individuals who experience sexual victimization, this can further complicate post-victimization recovery. In support of this notion, a study of US students found the association between sexual victimization and depression was greater for SGM individuals than cisgender heterosexual men (30)^•. Similarly, in a study of Quebecois cisgender college students, sexual victimization severity was more strongly associated with trauma symptoms among sexual minoritized women than heterosexual women (50)^•. Extending findings to substance use, among cisgender women presenting to a family planning clinic, sexual victimization was associated with heavier alcohol use in sexual minoritized women, but not heterosexual women (51)^•.

Contrary to these recent studies, others have not found support for interactions between sexual victimization and SGM identity in the prediction of depressive symptoms (52)^•, PTSD symptoms (30, 52)^•, or cigarette use (51)^•, such that the association between victimization and these outcomes did not vary by SGM identity. Moreover, in a sample of 60,200 US college students, unwanted sexual contact in the past year was associated with depression and suicidal ideation in both sexual minoritized and heterosexual students (53)^•. Further, Norris et al. (2021) found that sexual victimization was associated with a greater likelihood of past month cannabis use in heterosexual women, but not sexual minoritized women. Thus, findings regarding how SGM identity might contribute to negative post-victimization outcomes are mixed.

Relatedly, little is known about factors that promote resilience for SGM individuals who experience sexual victimization. In a national study of university students, a sense of belonging with the campus community served as a stronger buffer against post-victimization depression for sexual minoritized students relative to heterosexual students (53)^•. However, sexual victimization can negatively impact resilience factors. Consistent with a broader literature linking trauma exposure to deterioration of social support over time (54), sexual revictimization among sexual minoritized women was associated with lower social support (49)^•. Research informed by positive psychological factors (e.g., posttraumatic growth, resilience, social support) is greatly needed to highlight the unique strengths of SGM individuals and ways that resilience can be fostered following sexual victimization (55). With few exceptions, sexual victimization research has yet to widely consider the role of stigma in contributing to disparities in post-victimization outcomes among SGM individuals or resiliency factors that may promote post-victimization recovery. More research is needed in this regard.

Implications for Research

Earlier reviews of interpersonal violence in SGM populations (56, 57) identified critical weaknesses in the rigor of the literature that continue to persist today. These included: (1) few studies that distinguish between sex assigned at birth, sexual orientation, and gender identity; (2) poor operational definitions, and thus, inconsistent measurement of sexual victimization; (3) inadequate sample sizes; and (4) reliance on cross-sectional designs. Echoing these weaknesses, we propose the following recommendations in light of our recent literature review.

Recommendation 1: Improve Assessment

Notable limitations in assessment pervade the literature and weaken methodological rigor. For example, many studies rely on single, self-identification items of sexual orientation that offer limited response options for participants to choose from (e.g., lesbian/gay, bisexual, heterosexual). As such, we miss out on the nuance in how SGM individuals might otherwise identify (e.g., asexual, demisexual, pansexual), but also in the representation of SGM sub-groups. For instance, ‘mostly’ heterosexual is an identity that is distinct from both heterosexual and bisexual and makes up the largest SGM sub-group (58), yet is not captured in studies when this identity is not listed (i.e., this group will otherwise select ‘heterosexual’ over ‘bisexual’) (59). In addition, sexual orientation contains other components, including sexual attraction and behavior, which may or may not align with sexual identity (e.g., men who have sex with men). Further, gender expression, which is how an individual communicates their gender identity to others via their appearance, clothing, or mannerisms (14), is rarely assessed or reported in sexual victimization research. This is a considerable limitation as identity may be serving as a proxy for gender expression, though gender expression may be a more proximal risk factor for stigma-related discrimination or victimization (44)^•. Fine tuning our assessment, both in terms of identity and expression, will allow us to better understand the diversity of SGM experiences as well as identify SGM sub-groups that may be more hidden, yet at elevated risk.

Furthermore, there is a propensity in the literature to frame identity categories as predictors of sexual victimization and post-victimization outcomes for analytical purposes. While this practice may capture the differences between groups (e.g., SGM versus heterosexual and/or cisgender), minority stress theory posits that it is the experiences associated with marginalized identities – not the identities themselves – that lead to disparities. It will be essential to move away from using identity categories as proxies of minority stress and, instead, measure the putative mechanisms (i.e., stigma, minority stress) as the constructs of interest.

Another critical issue is that the most widely utilized measures to assess sexual victimization were developed from a heteronormative perspective (see (60)^• for exception). For example, the Sexual Strategies Scale (61) only assesses male-to-female perpetration and does not consider relationship type. Similarly, the Revised Sexual Experiences Survey (62) includes a range of tactics (e.g., verbal pressure, physical force, incapacitation), but does not include culturally-relevant tactics specific to the SGM community (e.g., threatening to expose the individual’s sexual or gender identity to others). Although recent efforts have been made to adapt this measure to include less heteronormative language (34)^••, these adaptations have not yet been widely tested nor implemented. Measures of sexual victimization perpetration and victimization must also be adapted to erase heterosexist bias that presumes male-to-female violence by assessing the perpetrator’s gender identity, sexual orientation, and relationship to the SGM individual. Beyond this, qualitative research exploring the nature and scope of sexual victimization experiences within the SGM community could help inform the creation of assessments better centered in SGM experiences. This necessary work in measurement development should be conducted and tested with feedback from the SGM community.

Recommendation 2: Address Contextual Factors

The study of sexual victimization in SGM populations must also account for the range of perpetrator types along a relationship spectrum (e.g., stranger, casual acquaintance, friend, romantic partner). While attention to this important contextual factor is often missing in sexual victimization research (63)^•, it is particularly relevant for SGM individuals, who may be at elevated risk for victimization from those they know – particularly romantic partners (64). Unfortunately, research “silos” exist, as sexual victimization research does not typically assess the relationship context and couples-focused research does not typically assess sexual victimization within the relationship. Thus, it is critical that future research break down these “silos” by adapting existing measurement approaches to more comprehensively assess sexual victimization both within and outside of intimate relationships. As the use of these methods begin to clarify victimization across different relationship types, research will be better equipped to examine individual and contextual risk factors to understand in what situations, and for whom, these effects are most likely to be observed. Until these goals are met, the field will be inadequately informed to develop effective and culturally-relevant prevention approaches.

Recommendation 3: Eliminate Sampling Biases

Research on sexual victimization suffers from sampling biases that systematically exclude SGM individuals or limit examination of sub-group differences. Sampling methods either assume that participants identify as heterosexual and cisgender or exclude SGM individuals for parsimony and/or concerns over sample size. While there are certainly studies that focus on sexual victimization in SGM individuals, such as those discussed earlier in this review, standard practice is to sample a specific subpopulation to the exclusion of other subpopulations. A related problem is the common practice to combine sexual minoritized individuals – across birth sex and/or sexual identity – into one group (i.e., LGB) to compare sexual victimization rates and post-victimization outcomes to heterosexual peers. This practice increases sample size and representativeness, but erases critical differences found even among SGM sub-groups. Together, these weaknesses make it difficult to examine similarities and differences in the risks and consequences of sexual victimization as well as the mechanisms that reinforce or maintain negative outcomes among SGM individuals. This is particularly problematic with respect to gender minoritized individuals, who are most likely to be excluded from sexual victimization research due to such sampling bias.

Collectively, these sampling methods are directly responsible for the marginalization and invisibility of SGM individuals in the sexual victimization research literature. Assumptions of heterosexuality predominate research, and thus, sexual and gender identity are rarely measured or reported. Consequently, SGM individuals and the unique stressors they experience are erased from empirical investigations of sexual victimization. To this end, we recommend (1) intentional efforts to oversample sub-groups of SGM individuals with careful consideration of gender versus sexual identity, and (2) assess and report sexual and gender identities to characterize the inclusion of SGM individuals in sexual victimization research, even when SGM individuals are not the central focus of the investigation. These best practices are critical to move the state of science forward to understand and address sexual victimization disparities.

Recommendation 4: Incorporate an Intersectional Approach

To improve the health and well-being of SGM individuals, research must consider the impact of intersectional identities and related experiences among SGM sub-groups (65). Intersectionality theory posits that multiple forms of oppression converge to create social conditions that facilitate discrimination (66). Thus, marginalized identities, including those related to sexual orientation, gender identity, and race/ethnicity, are best understood in combination. Given this, it is not surprising that individuals with multiple marginalized identities are more likely to have worse health outcomes than individuals with only one (67).

Within studies employing an intersectional approach, as noted previously, there is a tendency to use identity categories as predictors of negative outcomes. For example, Gilmore et al. (2021) found that sexual minoritized cisgender women who identified as Latinx reported less severe past year sexual victimization than White sexual minoritized cisgender women (68)^•. However, to more appropriately consider intersectionality, studies that focus on the mechanisms of sexual victimization (e.g., stigma, minority stress) are needed rather than categorical indicators such as sexual orientation, gender, or race/ethnicity. Understanding racially, ethnically, and economically diverse SGM in the context of multiple oppressions (51, 68) ^• is a necessary step for furthering our understanding of sexual victimization risk and post-victimization recovery. In doing so, the field will be better positioned to develop and implement prevention and interventions that address the unique social conditions, especially for SGM individuals of color and those of lower socioeconomic status.

Recommendation 5: Increase Use of Longitudinal Designs

In our review, the majority of new research published has been cross-sectional. Future studies must move beyond cross-sectional designs to incorporate measurement approaches that can more accurately capture (1) the proximal and temporal occurrences between relevant and unique SGM-related risk and protective factors of sexual victimization, and (2) developmental trajectories documenting sexual victimization and post-victimization outcomes over time and across the lifespan. This need could be best met with longitudinal panel designs, intensive longitudinal designs (e.g., daily diary or ecological momentary assessment), and/or measurement burst designs (e.g., longitudinal surveys with periods of daily diary or ecological momentary assessment). Among these, only intensive longitudinal designs allow for the assessment of proximal and temporal effects between variables to identify mechanisms of sexual victimization risks and consequences. Such designs are particularly well-suited to address both person-level (i.e., between-person) and situation-level (i.e., within-person) differences. In addition, only longitudinal panel designs and intensive longitudinal designs are able to assess developmental trajectories to consider the impact of sexual victimization on short- and long-term consequences as well as what factors reinforce or maintain consequences over time. We encourage future researchers to build on intensive designs focused on post-victimization outcomes among SGM individuals to date (61) to identify proximal risk factors of sexual victimization (27)^• among SGM individuals in future research. Overall, as these complexities are better understood, prevention and interventions can be directed at appropriate “upstream” targets.

Recommendation 6: Standardize Reporting

Lastly, standardized reporting requirements are critically needed to advance knowledge about the sexual victimization experiences of SGM individuals, particularly sub-group differences within this diverse population. For example, journals, as well as Editors of journals, could require reporting of sex assigned at birth, sexual identity, and gender identity as basic demographics in all articles. Further, standard practices should include detailed reporting of measurement strategies (e.g., instrumentation), particularly for sexual and gender identity measures. When examining sexual victimization, researchers should pay particular attention to reporting sexual victimization prevalence rates, including severity, in not just the overall sample, but also within SGM sub-groups. Journals, particularly those with broad readership, should request articles on this topic so that this work is not limited to special issues or SGM-focused journals whose readership is already aware of the critical need for this research.

Conclusion

SGM individuals are disproportionately impacted by sexual victimization. Our review of recent research in this area indicates replication of earlier results concerning higher prevalence rates and greater likelihood for SGM individuals to suffer from worse post-victimization outcomes when compared to heterosexual and cisgender individuals. However, gaps in knowledge persist, particularly the need to understand the unique role of minority stress on sexual victimization risk and its impact on subsequent coping and recovery. Limitations provide opportunities for future work to move beyond establishing prevalence to identify risk and protective factors that will most effectively facilitate prevention and intervention efforts among SGM individuals.

Human and Animal Rights

All reported studies/experiments with human or animal subjects performed by the authors have been previously published and complied with all applicable ethical standards (including the Helsinki declaration and its amendments, institutional/national research committee standards, and international/national/institutional guidelines).