Sexual minority identity and physical illnesses: Role of life course victimization and gender differences

Abstract

Introduction.

Sexual minority (SM) individuals experience higher rates of victimization and chronic physical health conditions. There are also known differences by gender in both victimization rates and victimization-linked chronic physical health conditions. However, few studies have examined gender differences regarding the association between SM identity and chronic physical health conditions via cumulative life-course victimization, cumulative childhood victimization, and cumulative adult victimization.

Methods.

The present research uses a nationally representative dataset - the National Longitudinal Study of Adolescent to Adult Health (data collected from 1994–2018) - to examine 1) cumulative violence victimization across the life-course and 2) the relative importance of violence victimization in childhood and adulthood as pathways between SM identity and chronic physical health conditions while estimating differences by gender. Data processing and analysis were conducted between 8/2021 and 12/2024.

Results.

Women who identified as Mostly Heterosexual and Bisexual were more likely to experience chronic physical health disparities via indirect associations through victimization accumulation across the life-course and violence victimization both in childhood and adulthood. Among Lesbian women there was an indirect association between sexual orientation and chronic physical health conditions via cumulative life-course victimization and childhood victimization.

Conclusions.

Findings demonstrate that for women who identify as Mostly Heterosexual and Bisexual, victimization-related chronic physical health vulnerabilities may manifest even before mid-life and both childhood and adult exposures are critical for physical health disparities in these groups. In contrast, childhood victimization maybe a more pervasive factor for chronic physical health conditions among Lesbian women.

Introduction

Sexual minority (SM) individuals are more likely to experience greater health disparities such as cardiovascular problems, diabetes, and cancer.^1–5 Moreover, SM adults also experience higher rates of victimization including more childhood abuse and neglect, life-course intimate partner violence and life-course sexual and criminal assault compared to their heterosexual counterparts. For example, research demonstrates that SM adults are 2.7 times more likely to experience violent criminal offenses and approximately 15% more likely to experience childhood physical abuse compared to heterosexuals.^6–10 Within the SM population, there is significant variability by gender in exposure to victimization and physical health disparities, such that SM women, especially mostly heterosexual and bisexual women, experience more violence victimization and health disparities throughout life compared to heterosexual individuals and SM men.^7,8,11,12

Exposure to victimization across the life-course has been linked to higher prevalence of chronic physical health problems and these associations are more pronounced among women.^13–22 To elaborate, experiences of victimization including exposure to childhood abuse, sexual violence, criminal assault, and cumulative violence across the life-course have been linked to chronic conditions including the onset and worsening of asthma, pain related disorders, diabetes, higher rates of cancer, and generally poorer health. ^13–22 Women who have been victimized, in particular, are at increased risk for chronic illnesses such as cardiovascular disease, cancer, asthma, and chronic pain.^{13,14,23–25}

Furthermore, experiences of victimization throughout life can be a driver of health disparities and inequities (e.g., cardiometabolic risk, asthma, depression, and worse physical health) between SM and heterosexual adults.^4,9,26–32 These findings are supported within the stress accumulation hypothesis of the life-course theory and biopsychosocial minority health perspectives which posit that chronic victimization can have a cumulative influence on negative physical health outcomes and could be instrumental in widening the gaps in health disparities experienced by SM adults.^33–36 However, even though SM women experience higher rates of victimization and greater physical health disparities and there is established evidence for the association between victimization accumulation and chronic physical health conditions among women, ^{8,11–14,23–25} research on differential associations by gender for the links between SM identity and chronic physical illnesses via accumulation of victimization across the life-course remain in the early stages. An examination of gender differences within the context of SM identity is important because it can help in understanding how both gender and SM identity together influence differential exposure to victimization and can provide a more nuanced understanding of victimization linked variability in health disparities among SM adults.

Studies have also demonstrated that developmental timing of victimization can influence health outcomes in SM populations and are rooted in the sensitivity and recency hypothesis of the life-course theory.^{29,30,37–42} According to the sensitivity hypothesis, exposure to stressors during sensitive periods of development (e.g., childhood) may be crucial for lifelong health and become biologically embedded. ^{40,41,43–49} For example, childhood victimization and multiple early-life victimization could be potential factors explaining physical health disparities between SM and heterosexual individuals.^39,42

In contrast, the recency hypothesis suggests that health outcomes may be influenced by more proximal experiences of stress.^43–48 For instance, in a recent study, researchers demonstrated that both childhood and adult victimization were important mechanisms for observed physical health disparities among mid-life SM adults and should be evaluated simultaneously to understand the unique influence of victimization at each developmental stage.³⁸ Given that SM women may be more susceptible to victimization across life and at different developmental periods ^7,8,11, it is important to examine gender differences in the association between SM identity and chronic physical health conditions via developmental victimization (childhood vs. adulthood). This will allow researchers to further unpack when in the life-course victimization experiences are more important for the observed gender-based heterogeneity in health disparities.

To address these gaps in current research, two main objectives were pursued: 1) to examine cumulative victimization across the life-course as a factor linking SM identity to chronic physical health conditions while testing differences by gender and 2) to explore differential associations by gender for the links between SM identity and chronic physical health conditions via cumulative victimization in childhood and cumulative victimization in adulthood to better understand the role of developmental timing for these associations at the overlap of SM and gender identity.

Methods

Study Sample

The present study uses a sample of 12,115 individuals from the nationally representative cohort study of individuals who were in grades 7–12 (N = 20,745) in 1994 - the National Longitudinal Study of Adolescent to Adult Health (Add Health).^50–52 Add Health respondents were followed over five waves of data collection with the most recently completed wave of data collected between 2016 and 2018 when the participants were entering mid-life (ages: 33–43).^50–52 This research was deemed exempt category 4 by the IRB at North Carolina State University.

Measures

Self-reported diagnosis or medication use for seven conditions that may have the most deleterious impact on health outcomes based on the Charlson Comorbidity Index was created to assess chronic physical health conditions (Wave V) by summing across all the chronic health conditions. The seven conditions included: ^53,54 1) cancer or leukemia, 2) high cholesterol, lipids or triglycerides, 3) high blood pressure, 4) diabetes, 5) asthma, chronic bronchitis or emphysema, 6) kidney disease, and 7) stroke.

Life-course cumulative victimization was measured (Waves I-V) as a pooled count of 1) criminal violence exposure across the life-course, 2) childhood abuse and neglect, 3) sexual assault, and 4) intimate partner violence. Criminal violence exposure across the life-course included getting shot, stabbed, beaten, and attacked with a knife at Waves I -V in the last 12 months and were measured both in adolescence and adulthood. Exposure was summed across all types of criminal violence exposure at each wave. Retrospective reports of childhood sexual, physical, and emotional abuse by a parent or caregiver before age 18 were assessed at Waves III-IV and each exposure was coded as 1 and no exposure for each as 0. Any experience of prior forced or coerced sexual assault at Waves IV-V was coded as 1 for each type of sexual assault and included reports of both exposures prior to age 18 and in adulthood. Intimate partner violence in adolescence and adulthood was measured at Waves II-V and included exposure to emotional and physical violence by a partner during adolescence and exposure to physical violence, threat of violence, and sexual violence by a partner in adulthood. Intimate partner violence exposure in adolescence (Wave II) was coded as 0 for no exposure and 1 for exposure. For intimate partner violence in adulthood (Waves III-V), each exposure type that was experienced in the previous 12 months at each wave was coded as 1 and if individuals reported exposures prior to the last 12 months but did not report intimate partner violence in the earlier waves, then they were assigned a score of 1 to account for their intimate partner violence exposure between waves. Victimization exposures were summed and then winsorized ⁵⁵ to 12 to avoid small cell sizes and extreme values.

The cumulative childhood victimization measure (Waves I-V) was created by pooling across exposures before age 18 and was capped at 7 to avoid extreme values and included exposure to 1) criminal violence exposure, 2) childhood abuse and neglect by a caregiver or parent, 3) sexual assault, and 4) emotional and physical partner violence in adolescence. Childhood victimization was winsorized ⁵⁵ to 7.

The cumulative adult victimization measure (Waves I-V) was created by pooling exposures occurring at or after age 18 to 1) criminal violence, 2) sexual assault, and 3) intimate partner violence, and capped to 8 to avoid small cell sizes and extreme values. Adult victimization was winsorized ⁵⁵ to 8.

At Wave V individuals self-reported their sexual orientation as “100% Heterosexual (straight)”, “mostly heterosexual (straight), but somewhat attracted to people of your own sex”, “bisexual that is, attracted to men and women equally”, “mostly homosexual (gay), but somewhat attracted to people of the opposite sex”, and “100% homosexual (gay)”. Following guidance from previous research,⁸ we combined the “mostly homosexual” and “100% homosexual” groups because based on results from t-tests, these two groups did not differ from one another for the three victimization measures and the chronic physical health conditions measure. The final SM identity groups included: 1. Mostly Heterosexual, 2. Bisexual, 3. Lesbian or Gay, and 4. Heterosexual (reference).

Model covariates included age, parent education in years, respondent’s education level in years, race (Black, Hispanic, Other, and White [reference]), and marital status (Divorced, Separated or Widowed, Never Married, Married [reference]). Covariate selection was based on directed acyclic graphs to identify potential confounders for victimization exposure and chronic physical health conditions.⁵⁶ In Add Health self-reported sex assigned at birth and gender identity are equivalent because a very small number of individuals reported discordant gender and biological sex which was suppressed to prevent deductive disclosure.⁵⁷

Statistical Analysis

Bootstrap mediation models⁵⁸ were estimated with 5000 bootstraps to test direct and indirect associations using Mplus v8.11 software.⁵⁹ Mediation models included cumulative life-course victimization was the mediator in Model 1 and both cumulative childhood victimization and cumulative adult victimization were mediators in Model 2 and for both models, gender differences were tested using multi-group analysis in Mplus.⁵⁹ All models were adjusted for covariates and probability weights and clustering variables were used to correct for Add Health’s complex sampling features.^57,60 Full information maximum likelihood was used for missing data with a missing at random assumption and can help improve precision of estimates. ⁶¹

Results

Population weighted statistics are presented in Table 1 (n = 12,115).

Table 1.

Population Descriptive Statistics (weighted; n = 12,115) by Gender

Men
Variables	% or Mean	na or se
Race: Black	13.74%	816
Race: Hispanic	11.28%	740
Race: Other	8.08%	602
Marital Status: Divorced, Separated or Widowed	15.40%	686
Marital Status: Never Married	29.17%	1474
Mostly Heterosexual	4.81%	234
Bisexual	0.91%	41
Gay or Lesbian	3.11%	178
Age	37.51	0.12
Parent Education	13.74	0.11
Respondent’s Education	14.14	0.10
Chronic Physical Health Conditions	0.65	0.02
Cumulative Life Course Victimization	2.76	0.08
Cumulative Victimization in Childhood	1.38	0.04
Cumulative Victimization in Adulthood	1.37	0.05
Women
Race: Black	15.36%	1410
Race: Hispanic	11.28%	977
Race: Other	6.98%	636
Marital Status: Divorced, Separated or Widowed	17.75%	1102
Marital Status: Never Married	25.74%	1778
Mostly Heterosexual	14.92%	1023
Bisexual	2.52%	136
Gay or Lesbian	2.08%	134
Age	37.28	0.12
Parent Education	13.66	0.11
Respondent’s Education	14.73	0.09
Chronic Physical Health Conditions	0.57	0.02
Cumulative Life Course Victimization	2.64	0.06
Cumulative Victimization in Childhood	1.41	0.03
Cumulative Victimization in Adulthood	1.20	0.03

Note:

^a- sample n (not weighted)

Results from Model 1 (Figure 1 and Appendix Table 1) indicate Mostly Heterosexual (b = 0.58, 95% CI = 0.09 – 1.06) and Bisexual (b = 1.44, 95% CI = 0.27 – 2.84) men had higher cumulative life-course victimization and all SM women experienced high cumulative life-course victimization (Mostly Heterosexual: b = 1.37, 95% CI = 1.10 – 1.64; Bisexual: b = 1.64, 95% CI = 0.65 – 2.61; Lesbian: b = 0.73, 95% CI = 0.14 – 1.43). Additionally, Bisexual (b = 0.25, 95% CI = 0.05 – 0.44) women had higher rates of chronic physical health conditions, and this association was indirectly linked via cumulative life-course victimization (b = 0.05, 95% CI = 0.03 – 0.08). There was also an indirect association via cumulative life-course victimization for Lesbian and Mostly Heterosexual women (Mostly Heterosexual: b = 0.06, 95% CI = 0.02 – 0.11; Lesbian: b = 0.03, 95% CI = 0.01 – 0.06).

Fig 1.

Association between sexual minority identity and chronic physical health conditions via cumulative life course victimization by gender. * p< 0.05, **p ≤ 0.01, *** p ≤ 0.001

Note: Models adjusted for covariate - Race, Age, Parent Education, Respondent’s Education and Marital Status; Reference Group - 100% Heterosexual. See Appendix Table 1 for all direct associations.

Based on Model 2 (Figure 2 and Appendix Table 2), all identities were linked with greater exposure to cumulative childhood victimization (Mostly Heterosexual: b = 0. 71, 95% CI = 0.56 – 0.85; Bisexual: b = 0.68, 95% CI = 0.27 – 1.12; Lesbian or Gay: b = 0.54, 95% CI = 0.17 – 0.91) among women. Bisexual (b = 0.86, 95% CI = 0.25 – 1.47) and Mostly Heterosexual (b = 0.63, 95% CI = 0.46 – 0.81) identities were linked to greater exposure to cumulative adult victimization among women. Among men, Mostly Heterosexual (b = 0.42, 95% CI = 0.03 – 0.83) identity was linked to greater exposure to cumulative adult victimization.

Fig 2.

Association between sexual minority identity and chronic physical health conditions via cumulative victimization in childhood and in adulthood by gender. * p< 0.05, **p ≤ 0.01, *** p ≤ 0.001

Note: Models adjusted for covariate - Race, Age, Parent Education, Respondent’s Education and Marital Status; Reference Group - 100% Heterosexual. See Appendix Table 2 for all direct associations.

Moreover, there was an association between SM identity and chronic physical health conditions for Mostly Heterosexual (childhood: b = 0.03, 95% CI = 0.01– 0.05; adulthood: b = 0.02, 95% CI = 0.01 – 0.04) and Bisexual (childhood: b = 0.03, 95% CI = 0.01 – 0.06; adulthood: b = 0.03, 95% CI = 0.01 – 0.06) women indirectly via cumulative childhood victimization and cumulative adult victimization. Among Lesbian women, there was an indirect association between sexual orientation and chronic physical health conditions via cumulative childhood victimization (b = 0.02, 95% CI = 0.01 – 0.04).

Given that there is evidence suggesting that types of victimization may also be important for health outcomes,^28–30,62 we also conducted sensitivity analysis (Appendix Tables 3–4) to test accumulation of victimization types: emotional (childhood caregiver emotional abuse and emotional abuse by partner in adolescence), physical (life-course partner violence and criminal victimization), and sexual (life-course sexual assault, adult partner sexual assault and sexual abuse by a caregiver) victimizations. Emotional (b = 0.08, 95% CI = 0.04 – 0.13) and sexual victimization (b = 0.06, 95% CI = 0.03 – 0.08) were linked with higher chronic physical health conditions among women. There were indirect associations via sexual (b = 0.03, 95% CI = 0.02 – 0.05) and emotional (b = 0.02, 95% CI = 0.01 – 0.03) victimization for Mostly Heterosexual women and indirect associations via sexual victimization among Bisexual women (b = 0.03, 95% CI = 0.01 – 0.06).

Discussion

The present study examines gender differences and builds upon prior research examining how violence victimization accumulation over the life-course and developmental victimization (childhood vs. adulthood) are linked to chronic physical illnesses among SM adults compared to their heterosexual peers. ^{4,9,26–32,39,42} Findings indicate that experiences of victimization over the life-course, across development, and by types may underlie the untimely onset of chronic physical health conditions among SM women entering mid-life.

To elaborate, study findings demonstrate that among Bisexual and Mostly Heterosexual women, the association between identity and chronic physical health conditions was indirectly explained by experiences of cumulative victimization across the life-course. Similarly, both childhood victimization and adult victimization indirectly linked Mostly Heterosexual and Bisexual identities to chronic physical health conditions. Among Lesbian women, childhood and cumulative life-course victimization were indirectly associated with higher levels of chronic physical health conditions. Moreover, results from the sensitivity analysis indicate that accumulation of life-course sexual victimization was indirectly associated with chronic physical health conditions among Bisexual and Mostly Heterosexual women and accumulation of childhood emotional victimization also indirectly influenced chronic physical health conditions among Mostly Heterosexual women.

Researchers have demonstrated that individuals, particularly women who report bisexual or mostly heterosexual identity, may experience stigma due to prevailing attitudes on monosexism and likelihood of identity misclassification.^63–65 Not feeling accepted for their identity can lead to negative psychological processes that may create feelings of invisibility, erasure, and isolation,^63–67 which could potentially exacerbate risks for victimization and chronic health disparities among Bisexual and Mostly Heterosexual women. Indeed, prior research has demonstrated that Bisexual and Mostly Heterosexual women are also at heightened risk for sexual victimization due to bisexual stigma ^65,68 and Mostly Heterosexual women experience greater childhood adversities.⁶⁹

And, findings from this research demonstrate that for Bisexual and Mostly Heterosexual women, life-course sexual victimization may be driving the indirect associations observed between identity and chronic health problems through accumulation of life-course victimization. Similarly, accumulation of emotional victimization in childhood could be playing an important role for the indirect association observed through cumulative childhood victimization on chronic physical health conditions among Mostly Heterosexual women.

Taken together, these findings have implications for future prevention efforts to reduce health disparities among SM women. These interventions could include both 1) preventative measures for reducing exposure to victimization among SM women such as bystander interventions, and policies and educational programs that reduce stigma and discrimination and 2) treatment focused interventions such as cognitive behavior therapy, batterer-focused interventions or mindfulness meditation that take a downstream approach to reducing stress and health harms of victimization.^70–77 Such efforts can focus on harm reduction due to life-course victimization exposure and childhood and adult victimization among Mostly Heterosexual and Bisexual women while focusing specifically on life-course sexual and childhood emotional victimization types for Mostly Heterosexual women and life-course sexual victimization for Bisexual women. For Lesbian women, preventative efforts could focus on reducing the harms of life-course victimization and childhood victimization.

Although Bisexual and Mostly Heterosexual men also experience stigma and feelings of erasure,⁶⁴ and both groups experienced cumulative life-course victimization and Mostly Heterosexual men experienced adult victimization in this study, victimization did not play a role in linking SM identity to chronic physical health problems for SM men. A methodological reason for these findings could be that fewer men compared to women report SM identity in the data, especially Bisexual identity. Additionally, prior research has demonstrated that although chronic health disparities exist between SM and heterosexual women well into mid-life and beyond, these health disparities although apparent between SM and heterosexual men in early adulthood, disappear in mid-life and late adulthood.¹² Moreover, other forms of minority stressors such as discrimination, prejudice, and microaggressions have consistently been associated with physical health disparities among SM men and could be more important factors linking sexual minority identity to chronic physical health disparities among SM men compared to violence vicitmization.^32,78

Limitations

The findings of this research are informed by several limitations. For instance, we were not able to examine race and ethnicity differences due to sample size issues but that should be considered in future research. The study was limited to examining chronic physical health conditions in early mid-life. Although retrospective adult reports have been used to study childhood adversities in SM populations,⁷⁹ SM identity in this study was assessed in adulthood and a few measures of childhood victimization were assessed in childhood which could be a limitation for the findings where childhood victimization indirectly influences the association between SM identity and chronic physical health conditions. Moreover, given the retrospective nature of some of the variables that make up our victimization measure and other data limitations, we were not able to assess victimization exposure in more refined developmental stages (beyond childhood and adulthood). Future research should examine developmental trajectories of victimization using a shorter periodicity.

Conclusion

Despite these limitations, the present research sheds light on how violence exposure, especially among SM women, can be critical for their overall physical health and has important implications for future research. Future research should examine changes in chronic health problems across the life-course and explore non-binary and transgender identities and previously identified mechanisms like inflammation⁸⁰ and mental health³¹ to further unpack the associations evaluated in this research. Moreover, future research should examine additional stressors (e.g., discrimination, prejudice, microaggressions) ^32,78 in larger samples of SM men and women to better understand the role of additional minority stress factors that contribute to chronic physical health disparities in the SM population.