The associations among sexual assault, posttraumatic stress, drinking to cope with anxiety and alcohol use based on gender identity and sexual orientation

Abstract

Background:

Sexual assault (SA) is experienced by a substantial proportion of emerging adult college students and is associated with elevated rates of Post-Traumatic Stress Disorder (PTSD) and alcohol use. The current study examines the mediating role of posttraumatic stress symptoms (PTSS) in the associations among SA severity, drinking to cope with anxiety, and average weekly drinks while considering the moderating roles of gender identity and sexual orientation.

Methods:

2160 college students diverse in gender (cisgender women, 64.4%; cisgender men, 30.6%, and transgender and gender diverse (TGD) individuals = 4.9%) and sexual orientation (heterosexual = 68.0%, LGBQ+ = 32.0%) completed measures of SA severity, PTSS, drinking to cope with anxiety motives, and average weekly drinks.

Results:

The mediation model for the full sample indicated significant indirect effects of SA severity on drinking to cope with anxiety through PTSS, but not on average weekly drinks. Moderation analyses revealed differential relationships between the variables based on both gender identity and sexual orientation. For instance, the association between SA severity and PTSS was stronger for cisgender women and TGD individuals compared to cisgender men, and for LGBQ+ individuals compared to heterosexual individuals. While the association between PTSS and average weekly drinks was only significant for cisgender men, the association between PTSS and drinking to cope with anxiety was significant for both cisgender men and women but not TGD individuals. Further, the association between SA severity and drinking to cope with anxiety was stronger for cisgender women than cisgender men.

Conclusions:

Findings from the current study demonstrate sexual orientation and gender identity differences and similarities in the associations of SA severity, PTSS, drinking to cope with anxiety, and alcohol use. Results are discussed in relation to the self-medication hypothesis and tailoring interventions for diverse groups.

Introduction

Sexual assault, defined as sexual contact without consent (Koss et al., 2007), is a common experience among college students. Sexual assault affects one in three college women (Koss et al., 2022), one in five transgender/gender diverse college students, and one in 15 college men (Cantor et al., 2020). For individuals of minoritized sexual orientations, the incidence rate is higher than their heterosexual peers, particularly among bisexual individuals (Cantor et al., 2020; Coulter et al., 2017; Edwards et al., 2015). Sexual assault experiences are associated with increased risk for psychopathology (Dworkin et al., 2017), and elevated rates of posttraumatic stress disorder (PTSD) than to other traumas (Creamer et al., 2001).

The directional nature of the association between sexual assault and alcohol use remains complex (Lorenz & Ullman, 2016). Unidirectional, bidirectional, and cyclical models of this association have all received empirical support (Yeater et al., 2022; Oshri et al., 2015; Parks et al., 2014; Testa et al., 2010; Turchik & Hassija, 2014), and the literature on whether sexual assault predicts increases in alcohol use is mixed (Hahn et al., 2019; Rhew et al., 2017; Testa et al., 2007; Testa & Livingston, 2000; Walsh et al., 2017). The self-medication hypothesis, which proposes that individuals may drink to cope with stressors, may explain the association between sexual assault and alcohol use (Khantzian, 1997). Applied to sexual assault, the hypothesis suggests that individuals with sexual assault histories may engage in alcohol use to cope with post-assault stressors such as subsequent sexual encounters (Bird et al., 2018), posttraumatic stress symptoms (PTSS), and related distress (Hawn et al., 2020). A daily diary study indicated that women with sexual assault histories use alcohol to reduce negative emotions (Stappenbeck et al., 2023). Understanding alcohol use post-assault is important, as alcohol use is a risk factor for revictimization (Testa et al., 2010).

Research examining the sexual assault self-medication hypothesis has predominantly focused on samples of cisgender women (Grayson & Nolen‐Hoeksema, 2005; Kaysen et al., 2006, 2007; Miranda et al., 2002). Most of the research on sexual assault and psychopathology has been conducted on predominantly White samples (Dworkin et al., 2017), particularly in the context of college populations. Research on disparities in sexual assault experiences and outcomes across diverse sexual orientation, gender identities, and in racial and ethnic diverse samples is nascent.

While cisgender men have lower prevalence rates of sexual assault than cisgender women and transgender/gender diverse individuals (Coulter & Rankin, 2017), among undergraduate students, 6.8% of men experience sexual assault (Cantor et al., 2020). Male college students are 78% more likely than same-age non-students to experience rape or sexual assault (Sinozich & Langton, 2014). Further, cisgender men who experience sexual assault have higher rates of problematic alcohol use (Turchik, 2012). Among college students, cisgender men are at a higher risk for coping motivated alcohol use compared to cisgender women, increasing their risk for alcohol-related consequences (Park & Levenson, 2002). A gap remains in the literature on the intersection of sexual assault, PTSS, alcohol use, and motives for drinking in samples of college men.

The literature on individuals from minoritized sexual and gender identities is growing but we lack empirical understanding of differences and disparities in models of psychopathology, such as the pathways of PTSS and alcohol use. Individuals of minoritized sexual orientation identities (e.g., LGBQ+) have higher rates of sexual assault than their heterosexual counterparts (Cantor et al., 2020; Conron et al., 2011; Eisenberg et al., 2021; McCauley et al., 2020; Scheer et al., 2021). Recent reviews found that individuals with minoritized sexual orientation identities have highly elevated lifetime prevalence estimates of sexual violence (Dworkin, Krahé, et al., 2021; Rothman et al., 2011). A substantial portion of transgender/gender diverse individuals experience sexual assault (James et al., 2016; Testa et al., 2012) but less is known about the impact in this population compared to cisgender individuals. While few studies examine PTSS among sexual and gender minorities, the existing evidence suggests elevated rates of PTSS among these minoritized identities (Alessi et al., 2013; Lehavot & Simpson, 2014; Paquette et al., 2021; Roberts et al., 2011).

There are notable disparities in alcohol use disorders for individuals from minoritized sexual orientation and gender identities (Evans-Polce et al., 2020; Jun et al., 2019). Research indicates that these individuals often engage in greater alcohol use more generally throughout their lifespan than cisgender, heterosexual individuals (Day et al., 2017; Krueger et al., 2020). A recent study found that estimated alcohol-related consequences are significantly higher per drink for sexual and gender minority identified individuals compared to cisgender, heterosexual men (Schipani-McLaughlin et al., 2022). LGBQ+ and transgender/gender diverse individuals experience minority-related stressors that may be compounded by sexual assault resulting in higher rates of PTSS and other post-sexual assault outcomes (e.g., drinking behaviors and coping motivations for drinking).

Psychological and alcohol use disparities observed among minoritized sexual orientation and gender identity individuals have been primarily explained via the minority stress model (Meyer, 2003) and the psychological mediation framework (Hatzenbuehler, 2009). Research suggests factors of minority stress uniquely predict deleterious outcomes, including PTSS and hazardous alcohol use (Coulter et al., 2015; Dworkin, Jaffe, et al., 2021; Wilson et al., 2016). Similarly, recent research suggests experiencing minority stress (e.g., stigma, discrimination, hate crimes) alongside gender and sexual orientation sociocultural components (e.g., less clear sexual scripts, gender expression expectations and stigma) may increase risk for sexualized violence and may exacerbate subsequent impacts on one’s sexual self, psychological wellbeing, or coping strategies (Ford & Becker, 2020; Bedera & Nordmeyer, 2020). In relation to elevated rates of alcohol use, experiencing minority stress has been associated with low coping efficacy – positing an additional explanation of why minoritized-identity individuals may engage in alcohol use to cope following a traumatic event (Dyar et al., 2019). Given the higher risk of experiencing traumatic events and stressors in contrast to their non-minoritized counterparts, LGBQ+ and transgender/gender diverse individuals may be at higher risk of trauma exposure, exacerbating coping strategies (e.g., alcohol use to attenuate PTSS; Bandermann & Szymanski, 2014; Szymanski & Henrichs-Beck, 2014).

While research has defined several motives for alcohol use (e.g., coping, enhancement, social conformity), coping motivated alcohol use may be particularly relevant to individuals from minoritized identities due to the increased prevalence of stressors (Dworkin, Cadigan, et al., 2018; Kalb et al., 2018; Tse & Wong, 2015). Emerging literature indicates initial support for the self-medication hypothesis in individuals from sexual minoritized identities (Banerjee et al., 2018; Bing-Canar et al., 2020; Dworkin, Cadigan, et al., 2018; Dworkin, Jaffe, et al., 2021; Gilmore et al., 2014; Rhew et al., 2017). Indeed, this would align with the psychological mediation framework that proposes reduced coping efficacy as one impact of ongoing minority-related stressors (Hatzenbuehler, 2009). Additionally, daily fluctuations in PTSS for sexual minority women have been associated with daily drinking to cope motives, which explained the number of drinks consumed on a given day (Dworkin, Cadigan, et al., 2018). Despite a growing emphasis on examining these intersecting paths of trauma-related stress and alcohol use and motives in LGBQ+ populations and the evidence for potential differences within these paths, there is still minimal research examining this in samples of transgender/gender diverse individuals or comparing across varied gender and sexual orientation identities.

The Current Study

The current study aims to extend the literature on the self-medication hypothesis by examining the mediating role of PTSS in the association between sexual assault severity and alcohol consumption and drinking to cope with anxiety motives. While past research examining these variables and pathways in emerging adult college students has been disproportionately White, non-Hispanic samples (Dworkin et al., 2017), the current study is conducted with a racial and ethnically diverse sample. This study examines the moderating roles of gender identity and sexual orientation in a mediation model. It is expected that sexual orientation and gender identity will moderate the associations between sexual assault severity, PTSS, alcohol consumption, and drinking to cope with anxiety.

Hypothesis 1:

Consistent with the self-medication hypothesis, it is expected that PTSS will partially mediate the association between sexual assault severity and alcohol consumption and drinking to cope with anxiety when assessed for the whole sample without moderators or covariates.

Hypothesis 2:

As both cisgender women and transgender/gender diverse individuals have higher rates of sexual assault and PTSD than cisgender men (James et al., 2016; Testa et al., 2012), it is expected that they will have a stronger association between sexual assault severity and PTSS than cisgender men.

Hypothesis 3:

As cisgender men report elevated rates of drinking to cope with trauma-related stress (Park & Levenson, 2002), it is expected that cisgender men will have a stronger association between PTSS and alcohol consumption and drinking to cope with anxiety than either cisgender women or transgender/gender diverse individuals.

Hypothesis 4:

As individuals from LGBQ+ identities have higher rates of sexual assault and PTSD (Cantor et al., 2020; Eisenberg et al., 2021), we hypothesized that LGBQ+ individuals would have a stronger association between sexual assault severity and PTSS than heterosexual individuals.

Hypothesis 5:

As minoritized groups have elevated stressors and daily diary studies have connected experiences of minority-related stress to alcohol use and coping motives for alcohol use (Dyar et al., 2019), it is expected that the association between sexual assault severity with drinking to cope with anxiety and alcohol consumption will be stronger for both transgender/gender diverse individuals and LGBQ+ identities than cisgender and heterosexual individuals.

MATERIALS AND METHODS

Participants and procedures

Participants were recruited from two American universities (southeast and southwest), to take part in a larger study on alcohol and health risk behaviors. Individuals were recruited by email invitations from registrar lists, flyers posted on campus and online, and through student research participant pools. Participants were told the purpose of this study was to understand alcohol use and health behaviors on their college campuses. Eligibility criteria included being an emerging adult (aged 18–25) and a full-time student attending the main campus of one of two minority-serving large public universities (confirmed by valid student email address). There were no additional exclusion criteria. Participants were compensated with a $15.00 USD gift card or class credit (if recruited through participant pools). All materials and protocols were approved by both institutions on November 2, 2021.

College students (N=2160) were recruited to have a relatively even split between universities (approximately 45% of the sample was recruited from university one and approximately 55% of the sample was recruited from university two). Additionally, less than 1% of the sample was recruited through participant pools. College students were recruited to also have a relatively diverse sample across gender identity and sexual orientation. The sample consisted of 1329 cisgender women (64.4%), 660 cisgender men (30.6%), and 106 transgender/gender diverse individuals (4.9%). Of the full sample, 32% identified as a sexual minority, 19.8% identified as Hispanic or Latino/a/x, and less than half the sample identified as White (45.28%). These demographics were consistent with the student bodies at both universities. Notably, the rates of transgender/gender diverse and sexual orientation identities were not reported by the universities. To ensure no duplicate or invalid responses were collected, valid student email addresses were confirmed at the time of enrollment and compensation.

Measures

Demographic information was collected on participants as outlined in Table 1.

Table 1.

Demographic information for the sample presented by gender identity group and for the full sample

	Cisgender men		Cisgender women		TGD individuals		Full sample
Continuous Variables	M	SD	M	SD	M	SD	M	SD
Age (18–25)	20.18	1.68	20.06	1.54	19.94	1.60	20.09	1.58
Categorical Variables	n	%	n	%	n	%	n	%
Sexual Orientation 1
Asexual	6	0.91	23	1.65	7	6.60	36	1.67
Bisexual	40	6.06	249	17.89	31	29.25	321	14.86
Gay	41	6.21	3	0.22	5	4.72	49	2.27
Heterosexual	549	83.18	915	65.73	4	3.77	1469	68.01
Lesbian	0	0.00	51	3.67	15	14.15	66	3.06
Pansexual	7	1.06	54	3.88	18	16.98	79	3.66
Queer	3	0.45	30	2.16	20	18.87	53	2.45
Questioning	11	1.67	62	4.45	4	3.77	77	3.56
Two-Spirit	1	0.15	0	0.00	0	0.00	1	0.00
Not listed	2	0.30	5	0.36	2	1.89	9	0.42
Prefer not to answer	0	0.00	0	0.00	0	0.00	0	0.00
Race
American Indian / Alaskan Native	3	0.45	15	1.08	0	0.00	18	0.83
Asian	195	29.54	264	18.97	13	12.26	472	21.85
Black / African American	86	13.03	305	21.91	18	16.98	409	18.94
Multiracial	51	7.72	130	9.34	7	6.60	188	8.70
Native Hawaiian / Pacific Islander	3	0.45	7	0.50	0	0.00	10	0.46
White	297	45.00	615	44.18	64	60.38	978	45.28
Prefer not to answer	25	3.79	56	4.02	4	3.77	85	3.94
Hispanic / Latina/o/x
No	510	77.27	1096	78.74	87	82.08	1695	78.47
Yes	124	18.79	284	20.40	19	17.92	427	19.77
Prefer not to answer	26	3.94	12	0.86	0	0.00	38	1.76
International Student
No	570	86.36	1331	95.28	103	97.17	2006	92.87
Yes	86	13.03	58	4.15	3	2.83	147	6.81
Prefer not to answer	4	0.61	3	0.21	0	0.00	7	0.35
First-generation Student
No	467	70.76	886	63.65	69	65.09	1424	65.93
Yes	186	28.18	495	35.56	36	33.96	717	33.19
Prefer not to answer	7	1.06	11	0.79	1	0.94	19	0.88
Sexual assault history 2
No	420	63.64	565	40.59	39	36.79	1025	47.45
Yes	240	36.36	827	59.41	67	63.21	1135	52.55
Regular drinker 3
No	386	58.48	676	48.56	62	58.49	1126	52.13
Yes	274	41.52	716	51.43	44	41.51	1034	47.87

Note. N = 2160.

¹Sexual orientation was later grouped into a binary variable to capture individuals identifying with a minoritized sexual identity (i.e., LGBQ+) or as heterosexual.

²Individuals with sexual assault history (yes) are those who endorsed at least one instance of any of the SES-SFV items, while those with no sexual assault history (no) are those who did not endorse any of the items.

³Regular drinkers are those who reported at least one drink on an average week on the DDQ while those who are not regular drinkers are those who reported 0s on an average week on the DDQ.

Gender identity was assessed by assessing individuals gender identity label (e.g., Woman, Man, Trans man, Trans woman, Genderqueer, Non-binary, Two-Spirit, Intersex) and their sex assigned at birth (male, female, Intersex). Participants who reported male or female for sex assigned at birth and a congruent gender identity (e.g., female sex at birth and identifies their gender as woman) were considered cisgender and divided into cisgender women or cisgender men. Participants who reported a gender identity that was incongruent from their sex at birth or reported Intersex were considered transgender/gender diverse.

Sexual orientation identity was assessed across identity labels of lesbian, gay, bisexual, queer, two-spirit, straight/heterosexual, questioning, pansexual, asexual, and other (with a write in option). Individuals who did not report straight/heterosexual were considered LGBQ+.

Sexual assault severity was assessed with the Sexual Experiences Survey – Short Form Victimization (SES-SFV; Koss et al., 2007) and scored based on nonconsensual acts (e.g., attempted coercion, rape), perpetrator strategy (e.g., through force), and chronicity (i.e., number of times the experiences happened) as per Davis and colleagues (2014). The sexual assault severity score includes 0, representing no sexual assault experiences. Reliability and validity of the SES-SFV is well documented and has been evaluated for sexual minorities (Anderson, et al., 2021; Canan et al., 2020; Johnson et al., 2017).

Posttraumatic stress symptoms were assessed using the eight-item version of the PTSD Checklist 5 (PCL-8; Price et al., 2016). Participants responded to symptom statements (e.g., “feeling jumpy or easily startled”) across the PTSD symptom clusters (i.e., intrusion symptoms, avoidance, negatively altered mood and cognitions, and alterations in arousal and reactivity). Participants rated items for the degree to which the symptoms bothered them in the past month by responding on a five-point scale (0=Almost never/never to 4=Almost always/always). Higher scores indicate a greater number and higher severity of PTSS (Cronbach’s α_{current sample}= 0.93).

Average number of weekly drinks was assessed using the Daily Drinking Questionnaire (DDQ; Collins et al., 1985). Participants reported their typical number of drinks consumed on each day of the week and the average number of weekly drinks was computed.

Drinking to cope with anxiety was assessed using the anxiety coping motives subscale of the five-factor modified Drinking Motives Questionnaire (DMQ; Grant et al., 2007). Participants responded to four anxiety coping motivations for alcohol use (e.g., “to reduce my anxiety”) by indicating the frequency with which their drinking is motivated by each statement (1=Almost never/never to 5=Almost always/always). Higher scores reflect greater frequency of drinking to cope with anxiety (Cronbach’s α_{current sample}=0.85).

Data Analyses

Analyses were conducted in R (Core R Team, 2022) using the Lavaan package (Rosseel, 2012) to complete a mediation model and two moderated mediation models with Distributionally-Weighted Least Squares estimation procedures to account for non-normally distributed variables (e.g., sexual assault severity was a bimodal distribution). Coefficient estimates were obtained using Bootstrapping with 1000 iterations. Missing data was handled using full information maximum likelihood opposed to imputation. Three individuals did not report their sex assigned at birth and were excluded in the gender identity moderation. For interpretability across variables in analyses, continuous variables (sexual assault severity, PTSS, average weekly drinks, drinking to cope with anxiety) were scaled (i.e., centered and standardized).

Three models were run. The first was a mediation model for the full sample for both outcomes (average weekly drinks and drinking to cope with anxiety) – which examined the extent to which sexual assault severity was associated with the two alcohol outcomes was due to PTSS. Two moderated mediation models were also conducted examining: (1) gender identity (two binary variables with either cisgender women or transgender/gender diverse individuals coded as 1, and cisgender men as the reference group) as a moderator of all three paths in the mediation model while controlling for sexual orientation (Heterosexual [0] vs. LGBQ+ [1]) and (2) sexual orientation as a moderator of all three paths in the mediation model while controlling for gender identity (the two binary variables). In sum, the moderated mediation models examined how much each of the paths in the mediation model were dependent upon gender identity (in model 1) or sexual orientation identity (in model 2). In all three models the covariance between weekly drinks and drinking to cope with anxiety was estimated.

RESULTS

All descriptive information for the continuous variables is reported in Table 2 by gender identity.

Table 2.

Descriptive information for the continuous study variables by gender identity group and for the full sample

	Cisgender men		Cisgender women		TGD individuals		Full sample
		95% CI		95% CI		95% CI		95% CI
Variable (Range)	M (SD)	(LL, UL)	M (SD)	(LL, UL)	M (SD)	(LL, UL)	M (SD)	(LL, UL)
SA Severity (0–63)	10.39 (20.41)	8.83, 11.95	15.29 (20.62)	14.20, 16.37	20.17 (23.60)	15.62, 24.72	14.03 (20.87)	13.15, 14.91
PTSS (0–32)	8.74 (8.80)	8.06, 9.43	12.49 (9.17)	12.01, 12.98	16.63 (8.96)	14.90, 18.36	11.59 (9.28)	11.19, 11.99
Drinking to Cope (0–5)	1.69 (1.08)	1.60, 1.77	1.86 (1.08)	1.80, 1.92	1.91 (1.10)	1.70, 2.12	1.81 (1.09)	1.76, 1.86
Weekly Drinks (0 – 54)	3.95 (7.60)	3.36, 4.53	3.61 (5.81)	3.31, 3.92	2.32 (3.99)	1.55, 3.09	3.65 (6.34)	3.38, 3.92

Note. N = 2160. SA Severity = the severity of sexual assault as derived from the SES-SFV according to scoring guidelines from Davis et al., 2014. PTSS = post-traumatic stress symptoms as measured by the PCL-8. Drinking to Cope = anxiety coping motives for alcohol use as measured by the Coping with Anxiety subscale of the five-factor DMQ. Weekly Drinks = Sum of the number of drinks reported for each day of the week on a “typical” week as measured by the DDQ.

¹Range reported is the observed range in the full sample.

Full sample mediation model

Figure 1 demonstrates the full mediation model of PTSS on the associations between sexual assault severity and average weekly drinks and drinking to cope with anxiety, with no moderators or covariates in the model. All paths in the model were significant, except for the association between PTSS and average weekly drinks (b1 path). Greater sexual assault severity was associated with elevated PTSS, more frequent drinking to cope with anxiety, and a higher number of average weekly drinks. PTSS, in turn, was associated with more frequent drinking to cope with anxiety. The covariance between average weekly drinks and drinking to cope with anxiety was also significant. In partial support of Hypothesis 1, the indirect effect of sexual assault severity on drinking to cope through PTSS was significant, though the indirect effect on average weekly drinks was not (see Table 3 for full results).

Figure 1.

Mediation model of PTSS mediating the associations between SA severity and both Average Weekly Drinks and Drinking to Cope with Anxiety for the whole sample with no covariates. Average Weekly Drinks and Drinking to Cope with Anxiety were allowed to covary. Solid lines are significant associations, while the dashed line is non-significant. SA Severity = Severity of sexual assault as measured by the SES-SFV. PTSS = Posttraumatic stress symptoms as measured by the PCL-8. Avg. Drinks = Average weekly drinks as measured by the DDQ. Drink to Cope = Coping with anxiety motives for alcohol use as measured by the five-factor DMQ.

Table 3.

Full model results for the base mediation model with the full sample

	Variables
Model Path	Predictor	Outcome	B	SE	p-value
a Path	SA severity	PTSS	0.278	0.025	< 0.001
b Path 1	PTSS	Avg. drinks	0.015	0.023	0.511
b Path 2	PTSS	Drink to cope	0.265	0.023	< 0.001
c Path 1	SA severity	Avg. drinks	0.225	0.029	< 0.001
c Path 2	SA severity	Drink to cope	0.198	0.026	< 0.001
Covariance	Avg. drinks	Drink to cope	0.350	0.025	< 0.001
Indirect effect	(SA sev. - PTSS - Avg. drinks)		0.004	0.006	0.513
Indirect effect	(SA sev. - PTSS - Drink to cope)		0.074	0.009	< 0.001

Note. All variables have been scaled (centered and standardized). SA severity (sev.) = severity of sexual assault as measured by the SES-SFV. PTSS = post-traumatic stress symptoms as measured by the PCL-8. Avg. drinks = Average number of weekly drinks as measured by the DDQ. Drink to cope = Anxiety coping motives for alcohol use as measured by the Coping with Anxiety subscale of the five-factor DMQ.

Moderation model for gender identity

Figure 2 depicts the moderated mediation model with gender identity as the moderator while controlling for sexual orientation. Greater sexual assault severity was associated with more PTSS (a path) for all three groups (cisgender women, transgender/gender diverse individuals, and cisgender men). In line with Hypothesis 2, there was a moderation of this path such that cisgender women and transgender/gender diverse individuals had a significantly stronger association between sexual assault severity and PTSS than did cisgender men. The pathway from PTSS to average weekly drinks (b1 path) was only significant for cisgender men and the pathway from PTSS to drinking to cope with anxiety (b2 path) was significant for cisgender men and cisgender women, but not for transgender/gender diverse individuals. In partial support of Hypothesis 3, this association (b2 path) was significantly stronger for cisgender men than cisgender women. While the associations for sexual assault severity with both average weekly drinks (c1 path) and drinking to cope with anxiety (c2 path) were significant for all three groups, contrary to Hypothesis 5, cisgender women had a significantly stronger association between sexual assault severity and drinking to cope with anxiety than cisgender men but this was not observed for transgender/gender diverse individuals. The indirect effects were significant for drinking to cope with anxiety for both cisgender men and cisgender women, but not transgender/gender diverse individuals. The indirect effects were not significant for any of the groups for average weekly drinks. The full model results are reported in Table 4.

Figure 2.

Mediation model observed in each of the three groups of the moderator (gender identity group) while controlling for sexual orientation identity as a binary variable (0 = Heterosexual; 1 = LGBQ+). Panel A is the model for cisgender men. Panel B is the model for cisgender women. Panel C is the model for TGD individuals. Solid lines are significant, while the dashed lines are non-significant. Bolder arrows indicate if that path is significantly stronger than the same path in another group.

Table 4.

Full results from the mediation model moderated by gender identity group while controlling for sexual orientation

	Variables
Group and Model Path	Predictor	Outcome	B	SE	p-value
Cisgender men
a Path	SA. Sev.	PTSS	−0.397	0.144	0.006
b Path 1	PTSS	Avg. Drinks	0.112	0.057	0.049
b Path 2	PTSS	Drink to Cope	0.359	0.048	< 0.001
c Path 1	SA. Sev.	Avg. Drinks	0.145	0.068	0.034
c Path 2	SA. Sev.	Drink to Cope	0.115	0.049	0.019
Cisgender women
a Path	SA. Sev.	PTSS	−0.853	0.175	<0.001
b Path 1	PTSS	Avg. Drinks	−0.005	0.026	0.840
b Path 2	PTSS	Drink to Cope	0.232	0.028	<0.001
c Path 1	SA. Sev.	Avg. Drinks	0.282	0.035	<0.001
c Path 2	SA. Sev.	Drink to Cope	0.242	0.031	<0.001
TGD individuals
a Path	SA. Sev.	PTSS	−0.866	0.177	<0.001
b Path 1	PTSS	Avg. Drinks	0.063	0.062	0.314
b Path 2	PTSS	Drink to Cope	0.147	0.103	0.153
c Path 1	SA. Sev.	Avg. Drinks	0.187	0.051	<0.001
c Path 2	SA. Sev.	Drink to Cope	0.206	0.096	0.031

Differences in path effects between groups (moderation effects)
a Path	CM to CW	SA. Sev.	PTSS	−0.457	0.075	<0.001
b Path 1	CM to CW	PTSS	Avg. Drinks	−0.117	0.063	0.063
b Path 2	CM to CW	PTSS	Drink to Cope	−0.127	0.057	0.027
c Path 1	CM to CW	SA. Sev.	Avg. Drinks	0.136	0.076	0.073
c Path 2	CM to CW	SA. Sev.	Drink to Cope	0.127	0.057	0.027
a Path	CM to TGD	SA. Sev.	PTSS	−0.469	0.102	<0.001
b Path 1	CM to TGD	PTSS	Avg. Drinks	−0.049	0.086	0.569
b Path 2	CM to TGD	PTSS	Drink to Cope	−0.212	0.113	0.062
c Path 1	CM to TGD	SA. Sev.	Avg. Drinks	0.042	0.087	0.484
c Path 2	CM to TGD	SA. Sev.	Drink to Cope	0.091	0.107	0.395
a Path	CW to TGD	SA. Sev.	PTSS	0.013	0.096	0.895
b Path 1	CW to TGD	PTSS	Avg. Drinks	−0.068	0.066	0.302
b Path 2	CW to TGD	PTSS	Drink to Cope	0.085	0.106	0.421
c Path 1	CW to TGD	SA. Sev.	Avg. Drinks	0.094	0.061	0.120
c Path 2	CW to TGD	SA. Sev.	Drink to Cope	0.035	0.100	0.724
Covariate effects for sexual orientation 1
		Sexual Orientation	PTSS	−0.051	0.028	0.071
		Sexual Orientation	Avg. Drinks	−0.033	0.047	0.482
		Sexual Orientation	Drink to Cope	0.059	0.050	0.237
Covariance		Avg. Drinks	Drink to Cope	0.342	0.024	<0.001

Indirect effects for each group
Cis. men	SA Sev. - PTSS – Avg. Drinks	−0.044	0.031	0.157
Cis. women	SA Sev. - PTSS – Avg. Drinks	0.005	0.023	0.846
TGD individuals	SA Sev. - PTSS – Avg. Drinks	−0.054	0.057	0.338
Cis. men	SA Sev. – PTSS – Drink to Cope	−0.142	0.056	0.011
Cis. women	SA Sev. – PTSS – Drink to Cope	−0.198	0.047	<0.001
TGD individuals	SA Sev. – PTSS – Drink to Cope	−0.127	0.096	0.187

Note. All variables have been scaled (centered and standardized). SA severity (sev.) = severity of sexual assault as measured by the SES-SFV. PTSS = post-traumatic stress symptoms as measured by the PCL-8. Avg. drinks = Average number of weekly drinks as measured by the DDQ. Drink to cope = Anxiety coping motives for alcohol use as measured by the Coping with Anxiety subscale of the five-factor DMQ.

¹Sexual orientation was included in the model as a dummy coded variable (heterosexual = 0, LGBQ+ = 1).

Moderation model for sexual orientation

Figure 3 depicts the moderated mediation model with sexual orientation identity as the moderator while controlling for gender identity. While the association between sexual assault severity and PTSS (a path) was significant for both heterosexual and LGBQ+ individuals, in support of Hypothesis 4, there was a stronger association for LGBQ+ individuals than for the heterosexual individuals. The association between PTSS and average weekly drinks (b1 path) was non-significant for both groups with no moderation effect. The association of PTSS with drinking to cope with anxiety (b2 path) was significant for both groups with no moderation observed. In contrast to Hypothesis 5, while the associations of sexual assault severity with both average weekly drinks (c1 path) and drinking to cope with anxiety (c2 path) were significant for both groups, there was no observed moderation effect. The indirect effects were significant for drinking to cope with anxiety for both heterosexual individuals and LGBQ+ individuals, but the indirect effects for average weekly drinks were not significant for either group (see Table 5 for full model results).

Figure 3.

Mediation model observed in both groups of the moderator (sexual orientation group) while controlling for gender identity as two binary variables (cisgender women to cisgender men: 0 = cisgender men; 1 = cisgender women; TGD individuals to cisgender men: 0 = cisgender men, 1 = TGD individuals). Panel A is the model heterosexual individuals. Panel B is the model for LGBQ+ individuals. Solid lines are significant, while the dashed lines are non-significant. Bolder arrows indicate if that path is significantly stronger than the same path in another group.

Table 5.

Full results from the mediation model moderated by sexual orientation group while controlling for gender identity

	Variables
Group and Model Path	Predictor	Outcome	B	SE	p-value
Heterosexual individuals
a Path	SA. Sev.	PTSS	0.138	0.037	<0.001
b Path 1	PTSS	Avg. Drinks	0.059	0.031	0.053
b Path 2	PTSS	Drink to Cope	0.286	0.030	< 0.001
c Path 1	SA. Sev.	Avg. Drinks	0.244	0.040	<0.001
c Path 2	SA. Sev.	Drink to Cope	0.189	0.032	<0.001
LGBQ+ individuals
a Path	SA. Sev.	PTSS	−0.367	0.061	<0.001
b Path 1	PTSS	Avg. Drinks	−0.008	0.036	0.818
b Path 2	PTSS	Drink to Cope	0.236	0.041	<0.001
c Path 1	SA. Sev.	Avg. Drinks	0.224	0.039	<0.001
c Path 2	SA. Sev.	Drink to Cope	0.219	0.042	<0.001

Differences in path effects between groups (moderation effects)
a Path	Het to LGBQ+	SA. Sev.	PTSS	−0.505	0.055	<0.001
b Path 1	Het to LGBQ+	PTSS	Avg. Drinks	−0.068	0.046	0.144
b Path 2	Het to LGBQ+	PTSS	Drink to Cope	−0.050	0.052	0.331
c Path 1	Het to LGBQ+	SA. Sev.	Avg. Drinks	−0.020	0.054	0.706
c Path 2	Het to LGBQ+	SA. Sev.	Drink to Cope	0.030	0.052	0.558

Covariate effects for sexual orientation 1
Cis. Men / TGD to Cis Women	PTSS	0.172	0.044	<0.001
Cis. Men / TGD to Cis Women	Avg. Drinks	−0.131	0.057	0.021
Cis. Men / TGD to Cis Women	Drink to Cope	−0.059	0.046	0.200
Cis. Men / Women to TGD	PTSS	−0.116	0.075	0.119
Cis. Men / Women to TGD	Avg. Drinks	−0.381	0.082	<0.001
Cis. Men / Women to TGD	Drink to Cope	−0.205	0.111	0.066
Covariance	Avg. Drinks	Drink to Cope	0.346	0.025	<0.001
Indirect effects for each group
Heterosexual	SA Sev. – PTSS – Avg. Drinks	0.008	0.005	0.095
LGBQ+	SA Sev. – PTSS – Avg. Drinks	0.003	0.014	0.824
Heterosexual	SA Sev. – PTSS – Drink to Cope	0.039	0.011	<0.001
LGBQ+	SA Sev. – PTSS – Drink to Cope	−0.087	0.021	<0.001

Note. All variables have been scaled (centered and standardized). SA severity (sev.) = severity of sexual assault as derived from the SES-SFV according to scoring guidelines from Davis et al., 2014. PTSS = post-traumatic stress symptoms as measured by the PCL-8. Avg. drinks = Average number of weekly drinks as measured by the DDQ. Drink to cope = Anxiety coping motives for alcohol use as measured by the Coping with Anxiety subscale of the five-factor DMQ.

¹Gender identity was included in the model as two dummy-coded variables to capture the three groups (Variable 1: cisgender men and TGD individuals = 0, cisgender women = 1; Variable 2: cisgender men and cisgender women = 0, TGD individuals = 1).

DISCUSSION

Sexual and gender minority identity individuals experience stressors through discrimination and societal stigma, and from experiences of victimization, including sexual assault. Increased alcohol use is thought to occur as a result of trying to manage distress from sexual assault and discrimination-related stressors. The current study examined the self-medication hypothesis in the context of sexual assault as moderated by diverse gender and sexual orientation identities. Research has established the disparities for minoritized sexual and gender identities in both alcohol consumption and risk for sexual assault (Day et al., 2017; James et al., 2016; Testa et al., 2012). This study expands on extant literature to examine the extent to which these theoretical models apply to transgender/gender diverse individuals. Using a diverse sample in terms of race and ethnicity in addition to gender and sexual orientation, the current study was able to explore PTSS, sexual assault severity, drinking to cope with anxiety, and alcohol consumption in the same models across different gender and sexual orientation identities. Results of this study demonstrated identity differences in the associations between sexual assault severity and PTSS, PTSS and drinking to cope with anxiety, and sexual assault severity and drinking to cope with anxiety, underscoring the importance of examining these hypotheses and models across diverse groups.

We expected that PTSS would partially mediate the association between sexual assault severity and alcohol consumption and drinking to cope with anxiety (Hypothesis 1). The findings provide partial support for the self-medication hypothesis as the indirect effect in the mediation model for the full sample was significant for drinking to cope with anxiety; however, it was not significant for average weekly drinks. While PTSS played a role in the association between sexual assault severity and drinking to cope with anxiety, it did not in drinking behavior. This is consistent with prior research in a cisgender sample that demonstrated sexual assault severity and PTSS were associated with drinking to cope, but not drinking behaviors (Testa et al., 2007). It may be that alcohol consumption is relatively stable for college students, while the motives for alcohol use are more susceptible to stressors and event-level changes in this population.

Prior prospective research has found that incapacitated sexual assault predicts for higher alcohol consumption and more negative alcohol-related consequences among cisgender college students (Kaysen et al., 2006). Another study found that in lesbian and bisexual community women, severe (but not moderately severe) sexual assault predicted increased rates of alcohol consumption and related consequences one year later (Rhew et al., 2017). Findings from the current study support this literature, with sexual assault severity significantly associated with PTSS, average weekly drinks, and drinking to cope with anxiety for all identities.

The indirect effect of sexual assault severity on drinking to cope with anxiety through PTSS was only significant for cisgender individuals, suggesting that there may be less evidence for the self-medication hypothesis in transgender/gender diverse individuals, or that there are other mediators that better explain the self-medication hypothesis for transgender/gender diverse individuals (e.g., minority stress). The indirect effects for drinking to cope with anxiety were significant for both heterosexual and LGBQ+ individuals when controlling for gender identity, while the indirect effects for average weekly drinks were not significant for either group. A systematic review examining the self-medication hypothesis and PTSS found that studies emphasizing sexual assault tended to be composed of predominately women (Hawn et al., 2020). A strength of the present study is that we examined the self-medication hypothesis with a gender diverse sample. This is particularly important given that the gender differences we have observed provide preliminary evidence that the self-medication hypothesis may not apply or may play out differently for transgender/gender diverse individuals, though further research using larger samples of transgender/gender diverse individuals and longitudinal methods are necessary.

The associations between sexual assault and PTSS, alcohol use, and drinking motives have been well established in cisgender women (Grayson & Nolen‐Hoeksema, 2005; Kaysen et al., 2006, 2007; Miranda et al., 2002) and have garnered empirical support in LGBQ+ individuals (Conron et al., 2011; Evans-Polce et al., 2020; Scheer et al., 2021). While cisgender women had a stronger association between sexual assault severity and drinking to cope with anxiety compared to cisgender men; in contrast to Hypothesis 5 (in which we predicted a stronger association between sexual assault severity and drinking for minoritized-identity groups), there were no observed differences in these associations for transgender/gender diverse individuals in comparison to cisgender men or women; nor was there a moderation effect based on sexual orientation. These findings of non-distinct associations between minoritized- and majoritized-identity individuals in sexual assault severity and alcohol variables provides some contrasting evidence that minority stress diminishes minoritized-identity individuals’ ability to cope adaptively in the face of stressors (Hatzenbuehler, 2009). Though additional research with models including minority stress is needed.

As predicted in Hypothesis 2, cisgender women and transgender/gender diverse individuals had a stronger association between sexual assault severity and PTSS than cisgender men. Similarly, in support of Hypothesis 4, for LGBQ+ individuals, sexual assault severity had a stronger association with PTSS than for heterosexual individuals. These findings are in line with extensive prior literature indicating cisgender women, LGBQ+ individuals, and transgender/gender diverse individuals are at elevated risk of experiencing sexual assault and subsequent PTSS compared to cisgender men and heterosexual individuals (Cantor et al., 2020; Conron et al., 2011; Eisenberg et al., 2021; Evans-Polce et al., 2020; James et al., 2016; Scheer et al., 2021; Testa et al., 2012). Interestingly, one study found that, in an undergraduate sample, transgender/gender diverse individuals had higher rates of trauma symptoms following sexual assault than cisgender individuals, but only sexual minority women and not sexual minority men experienced higher rates of trauma (Paquette et al., 2021). While direct rates of PTSS and sexual assault were not compared in the current study, there was a stronger association between sexual assault severity and PTSS for LGBQ+ individuals compared to heterosexual individuals even when controlling for gender identity in the model. The current results indicate that for individuals from minoritized sexual orientation identities, despite differences across gender, increases in sexual assault severity were associated with greater increases in PTSS than among heterosexual individuals. It may be that minority-related stress (Meyer, 2003) compound the association between sexual assault severity and PTSS. Indeed, prior research has demonstrated that daily experiences of minority-related stressors contribute to exacerbated PTSS in sexual minority women (Dworkin, Gilmore, et al., 2018).

We predicted that the association between PTSS and alcohol consumption and drinking to cope with anxiety would be stronger for cisgender men than either cisgender women or transgender/gender diverse individuals (Hypothesis 3). In partial support of this, increases in PTSS were associated with higher drinking to cope with anxiety for cisgender men compared to cisgender women. Notably, there are mixed findings in the literature around gender differences in stress-related coping. While one study found that cisgender men in college are more likely than cisgender women to engage in alcohol use for coping (Park & Levenson, 2002), a recent review indicated that women are more likely to drink to regulate stress than men (Peltier et al., 2019). Our results may be more closely related to the former study due to the similarities in our samples of emerging adult college students. Though evidently, gender differences require further examination to reach clear conclusions.

The association between PTSS and average weekly drinks was only significant for cisgender men. This aligns with prior research conducted with a sample of men and women with comorbid PTSD and alcohol use disorder (AUD), PTSD symptoms predicted greater AUD symptoms at a later assessment point for men, but not women (Bremer‐Landau & Caskie, 2019). It may be that the greater social acceptability of heavy alcohol use among men contributes to the association between PTSS and average weekly drinks (Nolen-Hoeksema & Hilt, 2006). Further, there was more variability in cisgender men’s average weekly drink reports, which could have allowed for an association to be more easily detected.

While the current study has numerous strengths in sample diversity and inclusive models, it has its limitations. For instance, collapsing across heterogeneous sexual orientations and across gender diverse identities prevents a nuanced understanding of identity in these associations. The transgender/gender diverse group was smaller than the cisgender samples, therefore, further research around these associations in transgender/gender diverse individuals should be conducted to lend credence to the results indicated by the current study findings. Notably, the LGBQ+ group was comprised of a larger portion of bisexual individuals than other sexual orientation identities, and the transgender/gender diverse group was comprised of more non-binary individuals (n=54) than other gender identities (e.g., transgender, n=10). The lack of psychometric support in minoritized-identity samples for some of the measurements is a potential limitation. Additionally, the analyses do not consider other minoritized and intersectional identities and groups, such as racial and ethnic identities. Future research should consider the unique and intersectional roles of racialized and ethnicity-based minoritized identities in these associations.

A limitation of the current sample is the consideration of only coping with anxiety motives for drinking. Future research should consider other motives for alcohol use and more nuanced assessment of coping motives (e.g., coping with depression). While we can speculate that the drinking to cope with anxiety motives were related to drinking to cope with PTSS, the lack of event specific data (e.g., ecological momentary assessment) prevents certainty. As such, further work should pursue more event-level data to confirm and extend these findings. The models include individuals who both are and are not regular drinkers (as indicated by at least one drink reported in an average week on the DDQ). As such, additional research on coping motives for drinking in response to PTSS and SA severity at different levels of drinking habits may be a useful extension of the current analyses. In line with this, the current study did not assess if students were drinkers or non-drinkers, which means the sample may include those who do not use alcohol at all. This may also impact the results differentially across different subgroups of the sample (e.g., trans and gender diverse students compared to cisgender men). Additionally, the lack of minority-related stress variables in the model prevents the understanding of the potentially compounding role of PTSS and minority-stress in drinking motives and behaviors. Further, PTSS were assessed generally, rather than resulting from sexual assault. Therefore, it is possible that the reported PTSS in the current study may be related to a different traumatic event.

The current sample was comprised of college students, indicating generally high functioning, well-educated, and resourced individuals. The literature would benefit from further assessment of these associations in diverse populations at higher risk for PTSS and AUD, such as military populations. This research could be further extended into a more nuanced examination of the self-medication hypothesis across identities by examining other forms of substances used for coping (e.g., cannabis use) and other specific trauma exposures (e.g., community violence).

This study was cross-sectional and correlational, therefore we cannot establish causation. The self-reported nature of the survey allows for recall errors. Lastly, the survey asked about sensitive information (e.g., sexual assault) that participants may not have been comfortable responding to openly and may have answered with socially desirable responses.

The findings from the current study demonstrate sexual orientation and gender identity differences and similarities in the associations of sexual assault severity, PTSS, drinking to cope with anxiety, and alcohol use. This study advances the knowledge on the role of sexual orientation and gender identity in sexual assault, alcohol use, and drinking motives in a racially and ethnically diverse sample of college students. It also extends the current literature on the self-medication hypothesis in the context of sexual assault by demonstrating sexual assault severity has a significant association with both PTSS and drinking to cope with anxiety across diverse identities, but that the indirect effect is not significant for transgender/gender diverse individuals. The results provide initial support for tailored interventions and secondary prevention efforts for different identity groups.