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International Journal of Transgender Health logoLink to International Journal of Transgender Health
. 2025 Oct 11;27(5):2597–2610. doi: 10.1080/26895269.2025.2568691

Adult sexual risk behavior in a Canadian sample of two-spirit, trans, and non-binary survivors of childhood sexual abuse

A Dana Ménard a,✉, Storm Balint a, Oliver Cheek a, Heather MacIntosh b
PMCID: PMC13618080  PMID: 42807443

Abstract

Background

Research on the impacts of CSA on survivors’ sexual outcomes as adults has found an increase in sexual risk behaviors, including earlier sexual debut, greater involvement in transactional sex, and having sex under the influence of alcohol/drugs, among others. However, the impact of CSA on adult sexual risk behaviors in two-spirit, trans, and non-binary (2STNB) individuals has not been investigated.

Objective

The goal of this investigation was to determine the impact of CSA on sexual risk as measured through a composite instrument in a sample of Canadian 2STNB adults and to identify contributors to this relationship.

Participants and setting

A sample of 309 Canadian 2STNB individuals was recruited through the assistance of community organizations; 125 identified having experienced CSA.

Methods

Participants completed an online survey including measures of adverse childhood experiences, sexual self-esteem (SSE), condom self-efficacy (CSE), symptoms of post-traumatic stress disorder (PTSD), experiences of interpersonal violence (IPV), and sexual risk behavior, as well as demographic questions.

Results

Path analysis demonstrated significant indirect effects from CSA to risk behavior through IPV and PTSD (β=.03, p<.05), and through IPV and CSE (β = -0.02, p < .05). The full sequential pathway from CSA through SSE and CSE to risk was not statistically significant (β = .04, p = .13), though significant pathways were observed between SSE and sexual risk (β=.38, p<.05), and from SSE to CSE to risk (β = .04, p < .05).

Conclusions

Experiences of CSA were associated with greater risk behavior in survivors through their experiences of IPV and PTSD symptoms. Focused attention on these mediators through education and therapy could help decrease risk behavior in survivors.

Keywords: CSA, non-binary, sexual risk, trans

Adult sexual risk behavior in two-spirit, trans, and non-binary survivors of childhood sexual abuse

Childhood sexual abuse (CSA) is a global problem affecting an estimated 7.6–16.7% of men and 18–26.7% of women (Chiu et al., 2013; Pereda, Guilera, Forns, & Gómez-Benito, 2009; Stoltenborgh, van IJzendoorn, Euser, & Bakermans-Kranenburg, 2011); the physical, sexual, and mental health impacts on survivors can be serious and lasting (Buckingham & Daniolos, 2013; Fix, Busso, Mendelson, & Letourneau, 2021; Maniglio, 2009). Multiple reviews have identified long-term impacts on survivors’ sexual risk1 behaviors as adults (e.g. Ménard & MacIntosh, 2021; Senn, Carey, & Vanable, 2008), which may increase the likelihood of contracting sexually transmitted infections and/or human immunodeficiency virus (HIV). This issue is a particular concern in the two-spirit, trans, and non-binary (2STNB) community, as children who identify as transgender or non-binary are more likely to be victimized than their cisgender counterparts. Prevalence rates of CSA in these groups may include up to 36% of transmasculine individuals and 18% of transfeminine individuals (Rimes, Goodship, Ussher, Baker, & West, 2019). However, to date, no studies have specifically focused on understanding adult sexual risk behaviors in 2STNB individuals with a history of CSA; the purpose of this investigation was to address this gap and also to identify possible contributors to the relationship between CSA and sexual risk behaviors in adulthood.

CSA and sexual risk behaviors in adults

Several systematic reviews have been generated on the connection between CSA and adult sexual risk behaviors. Across these reviews, participants with a history of CSA are more likely to report earlier sexual debut, greater involvement in transactional sex, sex under the influence of alcohol/drugs, multiple concurrent sexual partners or infidelity, higher number of partners/”promiscuity”, and increased rates of STI diagnoses (e.g. Abajobir et al., 2017; Arriola Louden, Doldren, & Fortenberry, 2005; Loeb et al., 2002; Paolucci, Genuis, & Violato, 2001; Senn et al., 2008). However, findings about the specific impacts of CSA on sexual risk have been inconsistent, likely reflecting inconsistencies in the methodology of research in this area. Most of these studies have focused on the impacts on cisgender, heterosexual female survivors. A few reviews have considered the sexual risk behavior of male2 CSA survivors who have male sexual partners (MSM). Findings from these reviews show greater rates of unprotected sex, higher number of partners, and greater involvement in transactional sex (e.g. Lloyd & Operario, 2012; Relf, 2001; Senn et al., 2008). Only a few studies have been done including cisgender, heterosexual men, and no reviews have been written; in most cases, they have been recruited as part of a mixed sample with cisgender heterosexual women. We have not identified any studies investigating the impact of early CSA on adult sexual risk behavior in samples of women who have sex with women, which is a serious omission in the literature given high rates of victimization in this group (i.e. 30% or more) (Bochicchio, Xu, Veldhuis, McTavish, & Hughes, 2024; Hequembourg, Livingston, & Parks, 2013). In short, the research on the relationship between CSA and sexual risk in adulthood is severely limited and results are both inconsistent and limited to a subset of the survivor population.

Researchers have attempted to identify additional variables that may impact the relationship between CSA and adult sexual risk behavior. High rates of revictimization in CSA survivors, including interpersonal violence (IPV), have been well-established in the literature; experiences of IPV have in turn been linked with sexual risk behavior (e.g. Duncan et al., 2018; Hill, Stein, Rossi, Magill, & Clarke, 2018). In samples of women, CSA and IPV have both been associated with risky sexual behavior (Combellick et al., 2019). Mental health concerns reported by survivors including alcohol use, trauma, depression, or Borderline Personality Disorder symptoms (e.g. Fuller-Thomson, Baird, Dhrodia, & Brennenstuhl, 2016) have also been associated with sexual risk behavior (Hébert, Amédée, Blais, & Gauthier-Duchesne, 2019). In a study of heterosexual male survivors, anxiety was found to significantly mediate the relationship between CSA and sexual HIV risk behavior (Peterson et al., 2018). Multiple studies with both female-only (Lemieux & Byers, 2008; Van Bruggen, Runtz, & Kadlec, 2006) and male and female CSA survivors (Krahé & Berger, 2017) have found associations between CSA, sexual self-esteem, and sexual risk behaviors (Lemieux & Byers, 2008), suggesting significant linkages between these constructs. The possibility of decreasing sexual risk behavior by building sexual self-esteem and sexual self-efficacy has also been noted with male and female adolescents (Rostosky, Dekhtyar, Cupp, & Anderman, 2008). However, it remains unclear whether these findings identified in survivors who identify as cis-gender or MSM would also apply to 2STNB persons.

CSA and trans/non-binary samples

The rate of childhood abuse and maltreatment among transgender and non-binary samples is extremely high, even in comparison to other LGB participants (Schnarrs et al., 2019). Some surveys have found up to 90% of trans/non-binary participants report having experienced some form of maltreatment, with over 75% reporting multiple forms of maltreatment (Higgins et al., 2025). Despite these high rates of maltreatment, only two studies could be located that focused on the adult sexual outcomes of CSA survivors who identified as trans or non-binary. Chen et al. (2023) collected data from a sample of 247 transgender women in China, of whom 14.2% reported a history of CSA; this group reported an increased risk of unprotected anal intercourse and having multiple partners. A study from the United States included 1,035 participants, of whom 88 identified as trans women; results showed that CSA in this group was associated with higher rates of unprotected anal sex, testing positive for any rectal STI, and HIV serostatus (Hall, Moran, Newcomb, & Mustanski, 2021). These associations tended to be stronger in Black and Hispanic/Latinx participants but lower in participants who identified as bisexual as opposed to gay.

Purpose of this investigation and hypotheses

The lack of research on adult sexual risk behaviors in transgender and non-binary survivors of CSA is a serious omission. Research has shown high levels of HIV in this population. A recent systematic review found that 19.9% of trans women and 2.6% of trans men were HIV positive (Stutterheim, Dijk, van, Wang, & Jonas, 2021). These rates are significantly higher for transgender people of color; CDC data shows that 44% of Black trans women are HIV positive (2022).

Perhaps most importantly, trans/non-binary individuals have reported that they want more information and education about their sexual health (Haley, Tordoff, Kantor, Crouch, & Ahren, 2019; Jayne, Szucs, Lesesne, Grose, & Johns, 2024). A qualitative study conducted by Mickel et al. (2024) found that participants wanted to receive information about STIs and sexual health, how to identify trans affirming health care providers, access to school-based sexual education programs, and identified online resources as preferred sources. In a recent study exploring the application of Developmental Couple Therapy for Complex Trauma with a group of 2STNB participants, all participants expressed concern about the lack of available resources for sexual health, wellbeing, and sexual healing following experiences of trauma in childhood (MacIntosh & McNamee, under revision).

Data on the factors contributing to adult sexual risk behaviors in trans/non-binary individuals is needed to support education and prevention, which will help address health inequities and disparities in this group. 2STNB survivors may be more likely to trust these education and treatment efforts if they know that the curriculum and interventions are based on research that has been inclusive of them and specific to their needs. Identifying the outcomes and relevant mediators of CSA in this group could help improve the establishment of treatment targets by mental health professionals who work with 2STNB clients, therefore protecting their health. It also allows for more targeted interventions, as the outcomes and mediators may vary significantly between 2STNB and cis survivors. Establishing whether there are problems related to CSA within the 2STNB community can also help community organizations justify applications for grant funding to create programs to address the issue. The purpose of this investigation was to understand the impact of CSA on adult sexual risk behaviors in 2STNB survivors. To that end, one main hypothesis was proposed, with two specific pathways.

Hypothesis 1

It was predicted that reporting a history of CSA would be associated with increased sexual risk behavior in adulthood among trans and non-binary individuals. This association would be fully mediated by the following pathways:

Hypothesis 1

a: CSA would increase vulnerability to trauma and revictimization, which in turn would elevate sexual risk through the following mechanisms:

  • CSA would be positively associated with intimate partner violence (IPV).

  • IPV would predict greater PTSD symptoms and lower condom self-efficacy.

  • PTSD would be associated with higher sexual risk behavior and lower condom self-efficacy.

Hypothesis 1

b: CSA would negatively impact sexual self-esteem, which would influence both protective and risk-promoting behaviors:

  • CSA would be negatively associated with sexual self-esteem.

  • Sexual self-esteem would positively predict condom self-efficacy.

  • Sexual self-esteem would be negatively associated with sexual risk behavior.

  • Condom self-efficacy would be negatively associated with sexual risk behavior.

Methods

Participants

Participants were recruited from across Canada and invited to participate in an online survey. Inclusion criteria for participants were: 1) identification as transgender (i.e. transgender men, transgender women, non-binary individuals, and/or two-spirit individuals), 2) residency in Canada, and 3) aged 18 years or older. The final sample consisted of 317 individuals, of whom 122 (38.5%) reported CSA. See Table 1 for demographic details.

Table 1.

Participant demographics (N = 317).

Demographics Number and percentage
Gender  
Transgender man 98 (30.9%)
Transgender woman 90 (28.4%)
Non-binary 115 (36.3%)
Agender 5 (1.6%)
Another gender identity 9 (2.8%)
Ethnic background  
North American 5 (1.6%)
North American Aboriginal 23 (7.3%)
European 165 (52.1%)
Latin American 4 (1.3%)
African 39 (12.3%)
Asian 33 (10.4%)
Caribbean 16 (5.0%)
Oceanic 2 (0.6%)
Multiethnic 19 (6.0%)
Prefer not say 10 (3.2%)
Unsure 1 (0.3%)
Sexual orientation  
Asexual 1 (0.3%)
Bisexual 80 (25.2%)
Gay or lesbian 62 (19.5%)
Heterosexual/straight 39 (12.3%)
Pansexual 30 (9.5%)
Queer 36 (11.4%)
Not listed 2 (0.6%)
Does not identify with one gender Identity 67 (21.1%)
Education  
Did not finish high school 14 (4.4%)
High School 97 (30.6%)
Some college 28 (8.8%)
College degree 48 (15.1%)
Some university 41 (12.9%)
Undergraduate 68 (21.5%)
Graduate/professional degree 21 (6.6%)
Age  
18–21 45 (14.1%)
22–25 70 (22.1%)
26–29 81 (25.5%)
30–39 110 (34.8%)
40–49 10 (3.1%)
50+ 1 (0.3%)
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Note. Participants were given the option “prefer not to say” for all demographic questions.

Measures

Demographics

Demographic items included questions about gender identity/sex assigned at birth, age, ethnic background, level of education, province of residence, relationship status, and sexual orientation. Participants were asked what steps, if any, they had taken toward social and/or medical transition (e.g. hormones, surgeries).

Adverse Childhood Experience Questionnaire (ACEs)

The Adverse Childhood Experience (ACE) Questionnaire (Felitti et al., 1998) was used to assess self-reported history of CSA. This 10-item questionnaire includes seven yes/no questions about adverse childhood events, including sexual, physical, and psychological abuse that occurred prior to the participant’s 18th birthday. Items include “Did a parent or other adult in the household often swear at you, insult you, put you down, or humiliate you?” and “Did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way.” Scores are calculated by summing the total of yes responses from 0 to 10. This measure has demonstrated good internal consistency and construct validity (Wingenfeld et al., 2011) and has been used in previous studies investigating childhood abuse experiences in transgender samples (e.g. Schnarrs et al., 2019).

Post-Traumatic Stress Disorder Checklist (PCL-5)

The PTSD Checklist for the DSM-5 (Weathers et al., 2013) is a self-report 20-item measure of PTSD symptoms, including memories, dreams, flashbacks, and negative feelings that may follow deeply stressful events. Participants rate items like “feeling very upset when something reminded you of the stressful experiences” and “trouble remembering important parts of the stressful experience” experienced over the past month on a 5-point Likert scale (e.g. 0 = not at all, 4 = extremely). All 20 items are summed to create an overall score, ranging from 0 to 80, with higher scores suggesting more severe PTSD symptoms. The PCL-5 has strong internal consistency, with a Cronbach’s alpha of .94, as well as strong test-retest reliability, and excellent validity (Blevins, Weathers, Davis, Witte, & Domino, 2015). This scale has been used to measure symptoms of PTSD in transgender populations in previous studies (e.g. Barr, Snyder, Adelson, & Budge, 2022).

Transgender-Specific Intimate Partner Violence Scale (T-IPV)

The Transgender-Specific Intimate Partner Violence Scale was used to measure experiences of IPV (Peitzmeier, Hughto, Potter, Deutsch, & Reisner, 2019; Peitzmeier et al., 2021). It consists of 14 yes/no items such as “Did a partner hide, damage, or destroy your hormones, clothing, or other items (e.g. makeup, binder, prosthetics) related to gender transition?” and “Did a partner force or pressure you into not pursuing aspects of gender transition that you wanted, such as name change, hormones, or surgery.” When respondents indicate that an item applies to them, they are then asked if this has occurred in the past 12 months. Quantitative scoring is de-emphasized with this scale, as any “yes” responses indicate that the individual has experienced trans-specific IPV. The T-IPV scale has shown good internal reliability and strong convergent validity in past investigations (Peitzmeier, Hughto, Potter, Deutsch, & Reisner, 2019, Peitzmeier et al., 2021). In this study, Cronbach’s alpha was .82.

Sexual Self-Esteem Inventory (SSEI)

The SSEI is a measure of sexual self-esteem defined by affective reactions to sexual thoughts, behaviors, and feelings (Doyle Zeanah & Schwarz, 1996). The measure’s five subscales include skill/experience, attractiveness, control, moral judgment, and adaptiveness. Individuals rate their agreement with 81 items on a 6-point Likert scale ranging from 1 (strongly disagree) to 6 (strongly agree) with overall scales ranging from 5 to 30. Examples of items in the SSEI include “I don’t think there’s anything wrong with my sexual feelings” and “I feel physically vulnerable in a sexual situation.” Raw scores for each of the subtests are summed, with several items reverse-coded, and then divided by the number of items to create average scores. The total score is calculated by determining the average of all five subscale goals. The SSEI has a strong reliability in samples of cisgender female survivors of sexual abuse (Shapiro & Schwarz, 1997). In this study, Cronbach’s alpha was .90.

Trans-Specific Condom/Barrier Negotiation Self-Efficacy (T-Barrier)

The Trans-Specific Condom/Barrier Negotiation Self-Efficacy scale (Dharma, Scheim, & Bauer, 2019) is a self-report measure designed to measure the self-rated ability of transgender individuals to engage in protected/safer sex in various scenarios. It consists of eight items rated on a 7-point Likert scale, ranging from 1 (not at all certain) to 7 (absolutely certain). Examples of items include “I can refuse sex when I don’t have a protective barrier available” and “I can ask a partner who truly sees me as the gender I know myself to be to use a protective barrier.” All eight items are summed to create an overall score, ranging from 0 to 56 with higher scores indicating higher self-efficacy. In this study, Cronbach’s alpha was .86.

Safe Sex Behavior Questionnaire (SSBQ)

The SSBQ (1992) is a composite measure of safe sex behaviors related to exposure and/or transmission of HIV, including items on assertiveness, condom use, avoidance of bodily fluids, and avoidance of anal sex (Dorio, Parsons, Lehr, Adame, & Carlone, 1992). The 24 items in the measure are rated on a 4-point scale ranging from 1 (never) to 4 (always) and include, “If I disagree with information that my partner presents on safer sex practices, I state my point of view” and “I abstain from sexual intercourse when I do not know my partner’s sexual history.” Certain items from this scale were modified to apply to 2STNB individuals; for example, “If I know an encounter may lead to sexual intercourse, I carry a condom with me” was edited to become “If I know an encounter may lead to penetrative sex, I carry a condom/barrier with me.” Negatively worded items are reverse-coded prior to summing all 24 items to create a total score, ranging from 24 to 96, with higher scores indicating the implementation of more safer sex practices. In this study, Cronbach’s alpha was .70, which is slightly below the commonly accepted threshold for reliability; however, this is generally considered acceptable in exploratory research or applied settings, particularly with understudied populations (Taber, 2018). Given the lack of validated safer sex measures tailored for 2STNB individuals, the construct was retained due to its conceptual importance.

Procedure

The present study was approved by the authors’ institutional review board at the University of Windsor (approval # 42839). Recruitment of participants involved assistance from multiple 2SLGBTQIA + community organizations as 2STNB individuals are considered a hard-to-reach population (Miner, Bockting, Romine, & Raman, 2012). Recruitment took place over social media as gender minority group members were often more easily recruited using these approaches (Guillory et al., 2018). Information about the study was provided in online posters and ads including an overview of the study, inclusion criteria for participants, and a link/QR code to the survey. Participants were made aware that most of the research team consisted of members of the 2SLGBTQIA + community.

Individuals were first directed to the informed consent form and were encouraged to complete the survey in a private space given the sensitive nature of the questionnaires. Participants were asked to answer demographic questions and then complete the measures listed above. Upon completion of the study, participants were provided with a debriefing letter and offered resources for extra support that could be accessed virtually as needed; these resources were also included in the informed consent form in case participants terminated the survey prematurely. Each participant was compensated for completing the survey with a $10.00 electronic gift card for Tim Hortons.

Analyses

Little’s MCAR test indicated that most missing data were missing completely at random (MCAR), except for PTSD (8.5%) and Safe Sex Behavior (12.6%). Although missing data over 5% can raise concerns (Tabachnick et al., 2013), maximum likelihood (ML) estimation is considered robust under MCAR or MAR conditions, particularly with large samples. Given that the sample exceeded Kline’s (1998) recommended ratio of 10–20 participants per estimated parameter, and normality assumptions were met, ML estimation was used to account for missing data and potential non-normality (Ory and Mokhtarian, 2010). Correlations between study variables are provided in Table 2.

Table 2.

Correlations between variables.

  Mean (SD) CSA IPV PTSD Sexual-self esteem Condom use Safe sex/sexual risk
CSA 0.38 (0.49) 1 0.409** 0.245** 0.130* −0.130* 0.045
IPV 0.66 (0.47)   1 0.291** −0.019 −0.305** −0.043
PTSD 33.68 (15.12)     1 0.089 −0.117** 0.243**
Sexual self-esteem 3.73 (0.46)       1 0.240** 0.435**
Condom Use 39.60 (8.61)         1 0.243**
Safe Sex 53.82 (8.63)           1
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**Correlation is significant at 0.01; *correlation is significant at 0.05

Results

The path model was assessed using RStudio and was evaluated using fit statistics such as the comparative fit index (CFI), Tucker-Lewis fit Index (TLI), the root mean square error of approximation (RMSEA), and the standardized root mean square residual (SRMR). The hypothesized model demonstrated good fit to the data: χ2 (6) = 10.99, p = .089; CFI = .976; TLI = .939; RMSEA = .054; SRMR = .041. All direct and indirect paths specified in the model were tested using a structural equation modeling approach with robust standard errors. Model pathways are illustrated in Figure 1 using unstandardized path coefficients. Table 3 presents the standardized direct effects and corresponding standard errors for each pathway, while Table 4 summarizes the unstandardized and standardized indirect effects of CSA on sexual risk behavior through the hypothesized mediators.

Figure 1.

Figure 1.

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Path model illustrating direct associations between childhood sexual abuse, mediators, and sexual risk behavior. Note. Unstandardized path coefficients are shown. ***p < .001.

Table 3.

Standardized direct effects and standard errors for direct pathways.

Pathway Standardized β SE
CSA → IPV 0.41 0.05
IPV → PTSD 0.29 1.89
CSA → Sexual self-esteem 0.11 0.05
Sexual self-esteem → Condom self-efficacy 0.25 0.94
PTSD → Condom self-efficacy −0.06 0.04
IPV → Condom self-efficacy −0.29 1.05
Sexual self-esteem → Risk 0.38 1.24
PTSD → Risk 0.21 0.03
Condom self-efficacy → Risk 0.17 0.05
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Note. Standardized beta (β) coefficients represent effect sizes for each pathway. In general, β ≈ .01 is considered small, β ≈ .09 is medium, and β ≥ .25 is large.

Table 4.

Indirect effects of CSA on sexual risk behavior through mediating variables.

Indirect pathways Unstandardized b Standardized β SE p
CSA → IPV → PTSD 3.72 0.12 0.93 <0.001
CSA → Sexual self-esteem → Risk 0.69 0.04 0.38 0.07
CSA → Sexual self-esteem → Condom self-efficacy → Risk 0.08 0.04 0.05 0.13
CSA → IPV → Condom self-efficacy → Risk −0.34 −0.02 0.13 0.008
CSA → IPV → PTSD → Condom self-efficacy → Risk −0.02 −0.01 0.02 0.41
CSA → IPV → PTSD → Risk 0.43 0.03 0.15 0.003
IPV → PTSD → Risk 1.07 0.06 0.33 0.001
Sexual self-esteem → CSE → Risk 0.78 0.04 0.29 0.007
PTSD → Condom self-efficacy → Risk −0.01 −0.01 0.01 0.400
CSA → Risk (total indirect) 0.83 0.05 0.47 0.08
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Note. Standardized beta (β) coefficients represent effect sizes for each pathway. In general, β ≈ .01 is considered small, β ≈ .09 is medium, and β ≥ .25 is large.

Hypothesis 1a proposed that experiencing CSA would be associated with increased sexual risk behavior in adulthood among 2STNB survivors, through multiple mediating pathways. Hypothesis 1a opined that the relationship between CSA and sexual risk behavior would be mediated by increased trauma and experiences of IPV. This hypothesis was partially supported. CSA significantly predicted greater IPV, which was associated with elevated trauma symptoms. Both IPV and trauma, in turn, significantly predicted sexual risk behavior. Specifically, significant indirect effects were observed from CSA to risk behavior through IPV and PTSD, and through IPV and condom self-efficacy. However, the pathway from trauma to condom self-efficacy was not statistically significant (see Tables 3 and 4).

Hypothesis 1b proposed that the association between CSA and sexual risk behavior would be mediated by decreased sexual self-esteem and condom self-efficacy. This hypothesis was partially supported. CSA was not significantly associated with lower sexual self-esteem. However, sexual self-esteem significantly predicted greater sexual risk behavior, and condom self-efficacy mediated the relationship between sexual self-esteem and risk. Despite these individual associations, the full sequential pathway from CSA through sexual self-esteem and condom self-efficacy to risk was not statistically significant. The total indirect effect of CSA on sexual risk behavior was not significant, β = .047, p = .07, suggesting that the combined indirect effects across all pathways did not reach the threshold for statistical significance.

The overall hypothesis, that CSA would be associated with increased sexual risk behavior through trauma, IPV, sexual self-esteem, and condom self-efficacy, was partially supported. The IPV- and trauma-related pathways (Hypothesis 1a) were supported, with significant indirect effects from CSA to risk via both PTSD and condom self-efficacy. Hypothesis 1b received partial support. Although CSA predicted lower sexual self-esteem this was not a significant predictor, and sexual self-esteem significantly predicted greater sexual risk behavior, the sequential indirect pathway through both SSE and condom self-efficacy was not significant.

Discussion

A history of CSA was associated with an increase in sexual risk behaviors in adult 2STNB survivors, providing preliminary evidence that the same relationships observed in samples of cisgender survivors (e.g. Loeb et al., 2002; Ménard & MacIntosh, 2021; Senn et al., 2008) are also present in 2STNB survivors. Significant indirect pathways were observed from CSA to risk via IPV and trauma, and via IPV and condom self-efficacy, offering strong support for the mediating role of IPV and trauma in this association. The relationship between CSA and IPV has been well-established in samples of cisgender women survivors (e.g. Barrios et al., 2015; Capaldi, Knoble, Shortt, & Kim, 2012; Girard, Dugal, Hébert, & Godbout, 2024), as well as the relationship between experiences of IPV and higher rates of HIV infection (e.g. Mittal, Porter, & Skračić, 2020). Both relationships were confirmed in this investigation with 2STNB survivors. Likewise, the association between CSA and trauma symptoms has also been well-established in cisgender survivors (e.g. Chen et al., 2010).

Both trauma and IPV may act together and separately to decrease survivors’ confidence in their abilities to advocate for safer sex practices. Threats of violence from a current partner may prevent survivors from communicating their needs to their partners. Survivors may prioritize their immediate safety over the risk of potential future sexual health issues (Mittal et al., 2020), for example, by agreeing not to use a condom to avoid emotional or physical abuse from a partner. Dependence on an abusive partner for financial, emotional, or other forms of support may also lessen survivors’ willingness to advocate for safer sex practices (Mittal et al., 2020). Even for those not currently in abusive relationships, threats of violence experienced in past relationships may impact survivors’ willingness to negotiate safer sex practices. More recent IPV may also heighten trauma symptoms for CSA survivors, leading to less safer sexual practices due to emotional dysregulation and impulsivity. Survivors may also use sex, particularly risky sex, as a way to distract themselves from trauma symptoms (Mota et al., 2019). Dissociation may make it difficult for survivors to communicate with their partners in the moment, preventing them from engaging in safer sex (e.g. Stappenbeck et al., 2016).

In the current study, SSE predicted condom self-efficacy and sexual risk behavior, but the relationship between CSA and SSE in the full model was not significant. There may be several explanations for this. Sexual self-esteem may be impacted more strongly in 2STNB individuals by factors other than a CSA history, like degree of gender congruence, symptoms of dysmorphia, access to gender affirming care and/or prosthetics, use of gender-affirming products (e.g. chest binder), or sexual aids (e.g. Kennis, Duecker, T’Sjoen, Sack, & Dewitte, 2022; Nikkelen & Kreukels, 2018). In general, transgender individuals have demonstrated lower scores on measures of sexual self-esteem and body image compared to cisgender individuals (Kennis et al., 2022); these may have stronger associations with sexual risk for this population regardless of CSA history. Sexual self-esteem may have been more strongly impacted by factors that are not unique to 2STNB individuals or CSA survivors but that were not assessed in this investigation, including body image. In previous studies, samples of transgender participants reported more problems related to body image and satisfaction (e.g. van de Grift et al., 2016), suggesting that this population may be more strongly impacted by body image in comparison to cisgender samples. Problems with body image may also be directly linked to transgender-specific experiences (e.g. access to gender affirming surgery), which is supported by findings showing increases in body image following the receipt of such care (e.g. van de Grift et al., 2016). The inclusion of a body image measure in addition to sexual self-esteem may be important for future research related to CSA victimization in transgender samples.

The relationship between sexual self-esteem and condom self-efficacy was significant, suggesting that individuals with higher sexual self-esteem were more confident in their ability to negotiate condom use. This highlights the importance of addressing factors such as sexual self-esteem in clinical settings and in sex education curricula to encourage safer sex practices in 2STNB individuals, regardless of victimization history. Although most pathways aligned with the conceptual model articulated, the positive association between condom self-efficacy and sexual risk behavior was unexpected. This may suggest that individuals with greater confidence in using protection may also be more sexually active or engage in behaviors classified as higher risk, but with a perceived sense of control or safety. These findings reflect broader research suggesting that “risk” does not always imply irresponsibility, particularly within marginalized populations who may navigate sexual experiences with a high degree of agency in complex social contexts. It may be more normalized for 2STNB individuals to engage in casual sex with various partners, as individuals who identify outside of hetero or cisgender-normative identities may subscribe to different sexual scripts or general relationship expectations (e.g. Harvey, Jones, & Copulsky, 2023). Those who engage in sex more frequently, with various partners, may feel more confident in their ability to communicate their wants, needs and expectations to their prospective partners, even while engaging with a behavior that has traditionally been identified as riskier. It is possible that 2STNB individuals are engaging in sex more often, or with more partners, but the specific sexual acts (e.g. oral sex versus penis-in-vagina penetrative sex) may be less risky than other types of sex acts, artificially inflating their sexual risk scores. Future research in this area should include a more granular measure of sexual activities to more precisely identify possible level of risk.

Implications

Results from the present study will be useful to several groups including researchers, clinicians, and sex educators working with the 2STNB population, as well as to CSA survivors and their partners. Historically, the 2STNB population has been excluded from sex research more broadly (Suen et al., 2020) and from CSA studies in particular (Ménard & MacIntosh, 2021); however, the high rates of victimization reported in past research (Rimes et al., 2019) as well as in this sample highlight the need for significant additional research with 2STNB samples. The results from this survey suggest that definitions of key constructs in this area of research and associated measures are applicable outside of traditional cisgender heterosexual samples. Participants in this study were given the opportunity to provide feedback on the face value of the survey and scales used; none reported significant concerns, suggesting that measures validated for use with cisgender populations may be acceptable for use in this group. Recruitment for this study was facilitated by the engagement of community partners, an approach that may be particularly relevant for this hard-to-reach population. CSA researchers who wish to collect data with these groups would be advised to reach out to relevant community organizations, as well as to consider the use of respondent-driven sampling (Heckathorn, 1997). This is especially true in the wake of scammer and bot attacks on this survey as well as others targeting LGBTQ+ samples and topics (Ménard, 2025), 2025). Results suggest the identification of several important mediators in the relationship between CSA and sexual risk behavior (i.e. trauma, IPV); further research on the role these constructs play could be useful, especially in the identification of treatment targets.

Findings from this study may be especially relevant for clinicians who work with 2STNB populations. Given the high prevalence rates of CSA observed in this study, all clinicians working with 2STNB clients would be advised to screen carefully for abuse experiences as these are likely to impact overall health and wellbeing, beyond sexual risk behavior only, in survivors. Several important mediators in the relationship between victimization and adult sexual outcomes were identified, meaning that regardless of the specific therapy goals established with 2STNB survivors (e.g. address trauma symptoms), there are likely to have spillover benefits to their sexual wellbeing. Given the role of IPV experiences in contributing to sexual risk behavior, clinicians are advised to ensure competency in this area to address this appropriately with their clients.

Given the high prevalence rates of CSA observed in this study as well as the deleterious impacts on adult functioning, sex educators would be advised to address abuse experiences directly with 2STNB individuals. Open discussions concerning CSA and the provision of resources and referrals may encourage survivors to seek treatment through the normalization of this process (Panisch, Faulkner, Fernandez, & Fava, 2020). 2STNB CSA survivors would benefit from the provision of sexual health information relevant to their gender identities (Hobaica, Schofield, & Kwon, 2019). Results identified several important mediators of the relationship between CSA and sexual risk, including condom self-efficacy, that would be modifiable through education and skill-building. Though sexual self-esteem was not differentially impacted by CSA, it still showed strong relationships with sexual risk behavior and condom self-efficacy across this sample of 2STNB individuals; it would therefore be valuable to help build these capacities with this population regardless of victimization experiences.

The results of this investigation are likely to be of significant interest to CSA survivors and to their partners. Findings may help survivors feel validation of their experiences and better understand their own behaviors in relation to sexuality and interpersonal relationships. Many important mediators were found in the pathways between early experiences and later adult sexual risk behavior, suggesting that these events are not deterministic but could be addressed through education, therapy, and corrective emotional experiences.

Limitations and future directions

The results of this investigation provide preliminary evidence on how CSA may relate to sexual risk behaviors for 2STNB survivors. Due to the nature of the study design (i.e. a cross-sectional survey), caution must be taken in making causal inferences; longitudinal study designs could clarify the directionality of relationship. However, given the young age at which victimization was first reported, it could be inferred that the abuse generally predated sexual risk behaviors for most of the sample. Data on other potentially relevant covariates (e.g. mental health symptoms in addition to PTSD, participation in therapy, experience of securely attached relationships, alcohol/substance abuse) were not collected and controlled. However, this is usually the case for other studies in the same area with cisgender, heterosexual survivors; therefore, findings from this investigation may still be comparable to the wider body of research. The results from this investigation were limited by how CSA was defined and measured; for example, results may not compare to studies that included non-contact CSA, where a younger age cutoff was used to identify survivors, or where CSA experiences were identified through medical records. The criteria used to identify CSA was also consistent with that used in several previous studies (e.g. Gewirtz-Meydan & Lahav, 2020) including with transgender samples (e.g. Feil et al., 2023; Schnarrs et al., 2019). Investigators in this area would be advised to replicate and extend findings using broader definitions and other measures of CSA to determine differential impacts on adult sexual outcomes.

Replication of these findings in a broader, more diverse sample (e.g. age, ethnicity) would be an important next step. To control for potentially confounding variables, survivors could be matched on demographic characteristics with 2STNB control participants (e.g. age, gender, sexual orientation, ethnicity) who do not report CSA experiences. In general, the creation of new scales and the validation of existing scales for use with 2STNB samples would be crucial for expanding research findings to this population; for example, current scales assessing sexual risk may not take into consideration factors such as the use of Pre-Exposure Prophylaxis (PrEP) or antiretroviral medications, which could impact individuals’ decision-making in this domain. Qualitative interviews would add depth and nuance to these findings and would also help in the identification of additional mediators and moderators that impact on the relationship between early abuse experiences and later adult risk behavior. Such research would also be crucial for identifying targets for clinical work with survivors and their partners.

Conclusion

Despite high rates of CSA in the 2STNB population, no research to date had examined the impact of these experiences on adult sexual risk behavior. A survey was conducted with 309 adults who identified as 2STNB, 125 of whom reported a history of CSA. The results of a path analysis showed that CSA significantly predicted greater IPV, which was associated with elevated trauma symptoms. Both IPV and trauma, in turn, significantly predicted sexual risk behavior. CSA predicted lower sexual self-esteem, which was associated with greater sexual risk behavior; condom self-efficacy significantly mediated the relationship between sexual self-esteem and risk. However, the full sequential pathway from CSA through sexual self-esteem and condom self-efficacy to risk was not statistically significant. These results suggest the impact of other mediators not measured in this study. In addition, significant mediators identified in this study could serve as valuable targets for therapeutic intervention. Further research with this population to better understand the relationship between CSA and adult sexual risk behavior is urgently needed.

Notes

1

We recognize that the word “risk” could be considered a loaded term, but it is the one used most commonly throughout the literature in this area and was kept for the purposes of locating this study within the wider body of scholarship.

2

Terminology use in this section reflects the wording and choices of the original authors. It is often unclear in published research in this area whether samples were exclusively cisgender or not.

Funding Statement

This work was supported by the Social Science and Humanities Research Council Partnership Engage program (PEG 892-2022-3093).

Disclosure statement

The authors declare that they have no conflict of interest.

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