Abstract
Objectives. To assess differences by gender of sexual partner in the association between sexual assault and alcohol use among women seeking care in college health centers.
Methods. This longitudinal study comprised 1578 women aged 18 to 24 years visiting 28 college health centers in Pennsylvania and West Virginia from 2015 to 2018. We used multilevel logistic regression and negative binomial regression, testing for interactions of gender of sexual partners, sexual assault, and prevalence and frequency of alcohol use and binge drinking.
Results. Sexual assault was reported by 87.3% of women who had sex with women or with women and men (WSWM), 68.2% of women who had sex with men only (WSM), and 47.5% of women with no penetrative sexual partners. The relative associations between sexual assault and alcohol outcomes were smaller for WSWM (prevalence: odds ratios from 0.04 to 0.06; frequency: incidence rate ratios [IRRs] from 0.24 to 0.43) and larger for women who had no penetrative sexual partners (IRRs from 1.55 to 2.63), compared with WSM.
Conclusions. Alcohol use patterns among women who have experienced sexual assault differ by gender of sexual partners.
Sexual assault (including sexual coercion, nonconsensual sexual contact, and rape) is prevalent among college students in the United States. While sexual assault affects individuals of all genders, findings from the Association of American Universities Campus Climate survey and other large campus-based studies suggest that 20% to 25% of cisgender women will experience sexual assault in college, compared with 5% to 7% of cisgender men.1–3 Research conducted in college settings has documented that sexual-minority women—those who identify as lesbian, gay, bisexual, or queer, or those who have same-gender sexual partners—are at similar risk or even greater risk for sexual assault than their heterosexual counterparts.3,4 Women who experience sexual assault are more likely than their peers without sexual assault histories to engage in health risk behaviors, such as the use of drugs and alcohol during sex,5 and report mental and behavioral health outcomes.6,7 Given the health and social consequences associated with victimization, the prevalence of sexual assault among women seeking care in college health settings is higher than that in the general population, warranting research on and intervention among this population.8
The relationship between alcohol use and sexual assault has received considerable attention in the literature. Research has documented the concurrence of and longitudinal associations between alcohol and sexual assault,9,10 with evidence to suggest that alcohol is a contextual factor in at least half of all sexual assaults on college campuses.11 Researchers emphasize that women’s alcohol use does not cause someone else to perpetrate violence against them. Rather, perpetrators may manipulate women’s alcohol consumption and take advantage of the pharmacological and psychological effects of alcohol.11 There is also evidence from community-based adult samples that suggests that alcohol is used as a coping mechanism by survivors after sexual assault.12,13 Research on the role of alcohol as both a contextual factor (before sexual violence takes place) and a behavioral outcome (after sexual violence takes place) is critical for informing interventions to reduce risk for revictimization and mitigate adverse health outcomes.
To date, much of the college sexual assault literature has focused primarily on the experiences of heterosexual women. Attention to the intersection of alcohol and sexual assault among sexual-minority women is important for several reasons. Sexual-minority women are at elevated risk for both sexual assault in childhood and adolescence14,15 and alcohol use and misuse,16–18 with evidence from a cross-sectional study to suggest that sexual-minority survivors are more likely than heterosexual survivors to endorse alcohol use as a coping mechanism.15
A recent study among sexual-minority women found deleterious effects of sexual assault on alcohol outcomes over time, indicating that cumulative sexual assault exposure was associated with greater levels of alcohol use and more alcohol-related consequences.9 However, this study was unable to compare whether these associations differed for sexual-minority and heterosexual women.
Sexual orientation health disparities research is often framed using Minority Stress Theory19 highlighting the ways that chronic heterosexist discrimination and inequity related to holding a minority sexual orientation “gets under the skin,”20 and manifests in coping behaviors16,17 and adverse mental health outcomes.19 We used this theory in the present study to examine whether sexual-minority women are more likely than heterosexual women to report alcohol use after sexual assault to inform trauma-informed interventions in the college health setting that acknowledge the health and developmental impacts of trauma.21
Another understudied group includes adolescent and young adult women who were not sexually active when they experienced sexual assault. Some studies have found that sexual assault survivors are more likely to avoid sexual intimacy after assault, while others have found associations between trauma and increased sexual risk behavior.22 However, outside of the child abuse literature, there has been little focus on the longer-term social and behavioral health outcomes of young women whose first sexual experiences were nonconsensual. Given nationally representative data suggesting a linear decrease since 2005 in the prevalence of adolescents who have ever had sex (and, thus, an increase in the prevalence of adolescents who have never had sex),23 this is a particularly important group to understand in the college health center context.
The purpose of the present longitudinal study of young women seeking care in college health centers was to assess (1) how sexual assault was related to alcohol use, (2) whether there were differences in the association between sexual assault and alcohol use among women who had sex with women or with women and men (WSWM) compared with women who had sex with men only (WSM), and (3) whether there were differences in the association between sexual assault and alcohol use among women who had no penetrative sexual partners compared with WSM. We hypothesized that the association would be larger for WSWM compared with WSM because of the compounding trauma of sexual minority–related stress and sexual assault.9 As the literature on sexual assault among women who had not previously had consensual sex is scarce, we did not have a priori hypotheses for the subpopulation of women with no penetrative sexual partners.
METHODS
We drew data from a longitudinal, cluster randomized controlled trial to evaluate a brief clinical intervention to reduce alcohol-related sexual assault among students seeking care from college health centers.8 This 2-armed randomized controlled trial included 28 college health centers on coeducational campuses in Pennsylvania and West Virginia that were randomly assigned to the intervention (a brief harm-reduction intervention for alcohol-related sexual assault) or control condition (a screening and brief intervention for alcohol use). In total, 2291 English-speaking young adults aged 18 to 24 years seeking care from participating college health centers were recruited into the study and completed baseline (time 1 [T1]), 4-month (time 2 [T2]), and 12-month (time 3 [T3]) computer-based surveys between September 2015 and March 2018. We used a combination of in-person and text message recruitment strategies, which are described in detail elsewhere.8 Interested participants completed informed consent procedures, which included a waiver of signed consent, and the baseline survey. Follow-up surveys were completed online. Participants received $15, $25, and $40 at T1, T2, and T3, respectively, to thank them for their time.
We used longitudinal data from all 3 time points from participants who identified as cisgender women, as determined by the correspondence between the participant’s sex assigned at birth and gender identity. Overall, few participants (range = 3–31) had missing data across any demographic variables at baseline. After we removed these participants, 7 participants were missing data for all sexual assault variables, and 12 were missing data for all alcohol use variables. Our final analytic sample comprised 1578 women.
Measures
Gender of sexual partners and demographic characteristics.
We used a behavioral assessment of sexual-minority status–gender of sexual partners. First, we asked if participants had ever had penetrative sex (vaginal or anal). Participants were also asked, “Since you started having sex, have you had sex with: men only, mostly men, both men and women, mostly women, or women only?”24 From these items, we categorized participants into 1 of 3 categories: (1) WSM, (2) WSWM, and (3) women with no penetrative sexual partners. Participants also indicated their age (in years, which we operationalized as ≥ 21 years and < 21 years), year in school (first-, second-, third-, or fourth-year undergraduate; graduate; or other), and race/ethnicity (White, Black, Asian, Hispanic/Latinx, or other).
Sexual assault history.
We assessed lifetime sexual assault victimization with a 6-item modified version of the Sexual Experiences Survey (Cronbach α = 0.83).25 Participants answered the following questions: How many times has anyone
fondled, kissed, or touched you sexually when you indicated that you didn’t want to?;
tried to have sex with you (but it did not happen) when you indicated that you didn’t want to?;
made you have vaginal sex when you indicated that you didn’t want to?;
made you do oral sex or have it done to you when you indicated that you didn’t want to?;
made you have anal sex when you indicated that you didn’t want to?;
penetrated you with a finger or objects (vaginally, orally, or anally) when you indicated that you didn’t want to?
Response options ranged from 0 to 4 or more times. T1 surveys assessed sexual assault exposure before college and since starting college, and follow-up surveys assessed exposure in the past 4 months (T2) and 12 months (T3). An affirmative response to any of these items indicated a positive history of sexual assault. We created a 4-category time-varying variable for analysis: no sexual assault, sexual assault before college only, sexual assault during college only, sexual assault before and during college.
Alcohol outcomes.
We measured current alcohol use by using participant reports of the number of drinking days and number of binge-drinking days (4 or more drinks in a 2-hour period) in the past 30 days.26 We coded participants who indicated 1 or more drinking days as using alcohol in the past month, while we coded participants who indicated 1 or more binge-drinking days as recently binge drinking. We operationalized frequency outcomes as continuous variables. We allowed responses to vary across all time points.
Analyses
We compared demographic characteristics by gender of sexual partners by using Rao–Scott χ2 analyses accounting for the clustering of individuals within schools. We used multilevel mixed-effects logistic regression for binary outcomes and negative binomial regression for continuous outcomes. We constructed 3-level models with random effects accounting for observations nested within individuals and for individuals nested within schools. We used the identity variance–covariance structure because this is a 3-level model with only random intercepts.
We engaged in a 3-step model-building process for each alcohol outcome. First, we examined the differences in outcomes by gender of sexual partners, controlling for legal drinking age, year in school, race/ethnicity, and study condition. Second, we added sexual assault history. Third, we added interaction terms for gender of sexual partners by sexual assault history. We created a categorical variable to represent each level of the sexual behavior–by–sexual assault interaction (with WSM and no sexual assault as the referent). We then calculated the ratio of odds ratios to understand the relative impact of sexual assault on study outcomes among WSM, WSWM, and women with no penetrative sexual partners (e.g., the odds of the outcome for women with sexual assault history vs those without sexual assault history, comparing WSWM to WSM). We conducted all analyses in Stata version 15 (StataCorp LP, College Station, TX).
RESULTS
Demographic characteristics of the sample are presented in Table 1. Almost two thirds of the sample (63.6%) were under the legal drinking age. Women with no penetrative sexual partners were generally younger than women who reported a history of penetrative sex. WSWM were more likely than WSM to identify as Black (13.7% vs 8.7%), while a larger proportion of women with no penetrative sexual partners identified as Asian (10.8%), compared with the proportion among both sexually active groups (3.9% among WSWM and 3.4% among WSM; P < .001). Sexual assault histories and alcohol use behaviors at T1, T2, and T3 are presented in Table 2. WSWM reported the highest prevalence of sexual assault and alcohol use at each time point, while women with no penetrative sexual partners reported the lowest prevalence of sexual assault and alcohol use at each time point.
TABLE 1—
Demographic Characteristics of Cisgender Women Seeking Services at 28 College Health Centers: Pennsylvania and West Virginia, 2015–2018
| Total Sample, % (No.) | Among WSM, % (No.) | Among WSWM, % (No.) | Among Women With No Penetrative Sexual Partners % (No.) | Pa | |
| Sexual minority status | 71.7 (1132) | 6.4 (102) | 21.8 (344) | ||
| Age, y | .08 | ||||
| ≥ 21 | 36.4 (574) | 38.2 (432) | 39.2 (40) | 29.7 (102) | |
| < 21 | 63.6 (1004) | 61.8 (700) | 60.8 (62) | 70.3 (242) | |
| Year in school | .007 | ||||
| 1st-year undergraduate | 26.3 (415) | 24.1 (273) | 30.4 (31) | 32.3 (111) | |
| 2nd-year undergraduate | 25.3 (399) | 24.7 (280) | 19.6 (20) | 28.8 (99) | |
| 3rd-year undergraduate | 21.9 (346) | 23.3 (264) | 19.6 (20) | 18.0 (62) | |
| 4th-year undergraduate | 16.0 (252) | 17.4 (197) | 19.6 (20) | 10.2 (35) | |
| Graduate | 7.3 (115) | 7.7 (87) | 2.9 (3) | 7.3 (25) | |
| Other | 3.2 (51) | 2.7 (31) | 7.8 (8) | 3.5 (12) | |
| Race/ethnicity | < .001 | ||||
| White | 71.0 (1121) | 71.6 (810) | 65.7 (67) | 70.9 (244) | |
| Black | 8.2 (130) | 8.7 (98) | 13.7 (14) | 5.2 (18) | |
| Asian | 5.1 (80) | 3.4 (39) | 3.9 (4) | 10.8 (37) | |
| Hispanic | 12.0 (190) | 12.8 (145) | 10.8 (11) | 9.9 (34) | |
| Other | 3.6 (57) | 3.5 (40) | 5.9 (6) | 3.2 (11) | |
| Study condition | .1 | ||||
| Control | 55.0 (868) | 57.2 (647) | 47.1 (48) | 50.3 (173) | |
| Intervention | 45.0 (710) | 42.8 (485) | 52.9 (54) | 49.7 (171) |
Note. WSM = women who had sex with men only; WSWM = women who had sex with women or with women and men. The sample size was n = 1578.
P values derived from the Rao–Scott χ2 test accounting for the clustering of individuals within schools.
TABLE 2—
Sexual Assault History, Recent Alcohol Use, and Recent Binge Drinking at Baseline (T1), 4-Months Postbaseline (T2), and 12-Months Postbaseline (T3) Among WSM, WSWM, and Women With No Penetrative Sexual Partners Seeking Services at 28 College Health Centers: Pennsylvania and West Virginia, 2015–2018
| WSM, % (No.) or Mean ±SD |
WSWM, % (No.) or Mean ±SD |
Women With No Penetrative Sexual Partners, % (No.) or Mean ±SD |
|||||||
| Characteristic | T1 | T2 | T3 | T1 | T2 | T3 | T1 | T2 | T3 |
| Sexual assault history | |||||||||
| Before college only | 22.9 (259) | 18.4 (208) | 14.7 (166) | 32.4 (33) | 26.5 (27) | 23.5 (24) | 16.3 (56) | 13.1 (45) | 11.6 (40) |
| Since starting college only | 16.5 (187) | 19.1 (216) | 20.8 (236) | 11.8 (12) | 12.7 (13) | 14.7 (15) | 14.5 (50) | 18.0 (62) | 19.8 (68) |
| Before and since starting college | 28.8 (326) | 33.3 (377) | 37.0 (419) | 40.2 (41) | 46.1 (47) | 49.0 (50) | 16.6 (57) | 19.8 (68) | 21.2 (73) |
| None | 31.8 (360) | 29.2 (331) | 27.5 (311) | 15.7 (16) | 14.7 (15) | 12.7 (13) | 52.6 (181) | 49.1 (169) | 47.4 (163) |
| Any recent alcohol use | 80.7 (892) | 78.4 (730) | 85.3 (763) | 87.8 (86) | 89.2 (66) | 86.8 (66) | 54.1 (185) | 55.7 (157) | 70.1 (197) |
| Any recent binge drinking | 54.1 (596) | 56.6 (526) | 58.5 (521) | 60.8 (59) | 62.2 (46) | 64.9 (50) | 29.2 (100) | 29.9 (84) | 40.6 (114) |
| Frequency of drinking daysa | 5.0 ±5.1 | 5.4 ±5.6 | 5.3 ±4.9 | 6.8 ±6.4 | 7.4 ±7.2 | 6.0 ±6.8 | 2.7 ±3.7 | 3.0 ±4.1 | 3.5 ±4.1 |
| Frequency of binge drinkinga | 2.2 ±3.4 | 2.4 ±3.6 | 2.2 ±3.1 | 3.1 ±4.1 | 3.8 ±5.9 | 2.9 ±4.5 | 1.0 ±2.3 | 1.0 ±2.3 | 1.3 ±2.3 |
Note. WSM = women who had sex with men only; WSWM = women who had sex with women or with women and men.
Number of days in past 30 days.
Alcohol Outcomes
Odds of recent alcohol use and recent binge drinking are presented in Appendix Tables A and B (available as supplements to the online version of this article at http://www.ajph.org). Compared with WSM, WSWM had significantly higher odds of recent alcohol use (adjusted odds ratio [AOR] = 2.70; 95% confidence interval [CI] = 1.28, 5.69), and reported a greater frequency of alcohol use (incidence rate ratio [IRR] = 1.32; 95% CI = 1.06, 1.63) and binge drinking in the past 30 days (IRR = 1.48; 95% CI = 1.08, 2.04). These associations were sustained after we controlled for sexual assault history. Women with no penetrative sexual partners had significantly lower odds of recent alcohol use (AOR = 0.18; 95% CI = 0.12, 0.26), and reported significantly fewer days of alcohol use (IRR = 0.52; 95% CI = 0.45, 0.59) and binge drinking (IRR = 0.38; 95% CI = 0.31, 0.47) compared with WSM. These associations were also sustained after we controlled for sexual assault history.
In models controlling for gender of sexual partners (Appendix Table A), women who experienced sexual assault during college (AOR = 2.62; 95% CI = 1.70, 4.03), and women who experienced sexual assault before and during college (AOR = 4.30; 95% CI = 2.89, 6.40) had higher odds of recent alcohol use compared with women with no sexual assault history. Women who experienced sexual assault during college only (AOR = 3.44; 95% CI = 2.36, 5.02) and women who experienced sexual assault before and during college (AOR = 4.03; 95% CI = 2.87, 5.68) also had higher odds of recent binge drinking, compared with women with no sexual assault history. All 3 sexual assault exposures were associated with greater frequency of alcohol use (IRRs ranged from 1.19 to 1.80) and binge drinking (IRRs ranged from 1.27 to 2.39) when we controlled for gender of sexual partners (Appendix Table B).
Interactions of Sexual Assault and Gender of Sexual Partners
We present each combination of sexual assault history and gender of sexual partners in Table 3. Compared with WSM with no sexual assault history, WSWM who experienced sexual assault before and during college had higher odds (AOR = 5.04–6.67) and rates (IRR = 1.97–3.01) of alcohol use and binge drinking, while women with no penetrative sexual partners and who reported precollege sexual assault exposure had lower odds (AORs = 0.29–0.44) and rates (IRRs = 0.48–0.57) of alcohol outcomes. However, the ratio of odds ratios and ratio of rate ratios presented in Appendix Tables A and B illustrate that the relative associations between sexual assault history and alcohol outcomes were smaller among WSWM (AORs = 0.04–0.06; IRRs = 0.24–0.43) and larger among women with no penetrative sexual partners (AOR = 3.13; 95% CI = 1.29, 7.57; IRRs = 1.55–2.63), than among WSM.
TABLE 3—
Odds Ratios of Any Past-Month Alcohol Use and Any Past-Month Binge Drinking and Incidence Rate Ratios of Frequency of Past-Month Alcohol Use and Frequency of Past-Month Binge Drinking of the Interactions of Gender of Sexual Partners and Sexual Assault History Among Women Seeking Services at 28 College Health Centers: Pennsylvania and West Virginia, 2015–2018
| Gender of Sexual Partners by Sexual Assault History | Any Alcohol Use, OR (95% CI) | Frequency of Alcohol Use, IRR (95% CI) | Any Binge Drinking, OR (95% CI) | Frequency of Binge Drinking, IRR (95% CI) |
| WSM | ||||
| No sexual assault (Ref) | 1 | 1 | 1 | 1 |
| Sexual assault before college | 1.61 (0.98, 2.65) | 1.18 (1.00, 1.38) | 1.16 (0.75, 1.80) | 1.20 (0.94, 1.54) |
| Sexual assault during college | 2.40 (1.44, 4.02) | 1.41 (1.21, 1.63) | 2.76 (1.79, 4.26) | 1.74 (1.39, 2.20) |
| Sexual assault before and during college | 4.12 (2.59, 6.58) | 1.70 (1.48, 1.96) | 3.54 (2.39, 5.23) | 2.08 (1.68, 2.57) |
| WSWM | ||||
| No sexual assault | 27.56 (3.37, 225.24) | 2.68 (1.64, 4.36) | 4.92 (1.28, 18.88) | 3.22 (1.56, 6.67) |
| Sexual assault before college | 1.70 (0.55, 5.22) | 1.30 (0.91, 1.86) | 1.26 (0.46, 3.44) | 1.25 (0.72, 2.17) |
| Sexual assault during college | 10.84 (1.29, 90.84) | 1.21 (0.70, 2.09) | 2.74 (0.64, 11.64) | 1.34 (0.59, 3.05) |
| Sexual assault before and during college | 6.67 (2.16, 20.61) | 1.97 (1.48, 2.63) | 5.04 (2.19, 11.60) | 3.01 (1.96, 4.63) |
| Women with no penetrative sex partners | ||||
| No sexual assault | 0.20 (0.12, 0.34) | 0.45 (0.37, 0.54) | 0.16 (0.09, 0.27) | 0.27 (0.19, 0.37) |
| Sexual assault before college | 0.29 (0.13, 0.67) | 0.57 (0.42, 0.78) | 0.44 (0.20, 0.99) | 0.48 (0.29, 0.78) |
| Sexual assault during college | 0.71 (0.33, 1.54) | 1.14 (0.88, 1.48) | 1.37 (0.67, 2.79) | 1.23 (0.83, 1.81) |
| Sexual assault before and during college | 1.35 (0.63, 2.88) | 1.18 (0.92, 1.52) | 1.11 (0.57, 2.20) | 1.30 (0.88, 1.91) |
| P for interaction term (derived from χ2 test) | < .001 | < .001 | < .001 | < .001 |
Note. CI = confidence interval; IRR = incidence rate ratio; OR = odds ratio; WSM = women who had sex with men only; WSWM = women who had sex with women or with women and men. All models controlled for legal drinking age, year in school, race/ethnicity, and study condition (intervention or control), and accounted for individual and school-level clustering.
DISCUSSION
In this longitudinal study of women seeking services in college health centers, we found that sexual violence was prevalent and associated with alcohol use. The prevalence of sexual assault was higher among WSWM (87.3%) and lower among women with no penetrative sexual partners (47.5%), compared with WSM (68.2%). The associations between sexual assault and alcohol outcomes differed across these groups whereby the association was smaller among WSWM and larger among women with no penetrative sexual partners, compared with WSM. Research suggests that survivors may not seek formal campus resources, like a health center, for sexual assault because of perceptions that formal systems cannot help or may cause further harm.27 Therefore, our findings likely do not capture the experiences of the most marginalized college students. Nevertheless, our findings emphasize that college health centers should be considered partners in sexual violence prevention and response efforts on college campuses as they serve a population at high risk for sexual assault and have mechanisms for promoting resilience, safety, and acceptance for all students, which are principles of trauma-informed care.28
The finding that emerged most contrary to our hypotheses was that the relative association between sexual assault and alcohol use was smaller for WSWM than WSM. With Minority Stress Theory19 as a guiding framework, research has documented the ways that the chronic social and structural adversities (e.g., heterosexist discrimination, policies and practices that minimize the needs of populations experiencing marginalization) faced by sexual minorities increase risk behavior and are associated with poor health outcomes among this population. For example, studies among adolescent and adult sexual-minority samples have found that experiencing psychological distress and sexual orientation–based victimization is associated with drug and alcohol use.29,30 Assuming sexual minority status is a risk marker for bias-based discrimination, we hypothesized that the impact of sexual assault on alcohol would be larger, not smaller, among WSWM given the confluence of multiple types of violence victimization that WSWM experience and evidence that revictimization is associated with higher levels of distress compared with experiencing 1 or no forms of victimization.31 Our findings may illustrate that sexual assault is only 1 exposure of many for WSWM that increase the likelihood of alcohol use in young adulthood. Future research could assess the proportion of population attributable risk ascribed to multiple types of adversity to explore this hypothesis.
It is also possible that research with college-age WSWM addresses sexual assault and alcohol use too late. Specifically, WSWM in this study were likely already using alcohol to cope with sexual assault given the elevated prevalence of sexual assault and alcohol use among WSWM at baseline. Sexual violence prevention with middle- and high-school youths would be strengthened by more explicitly addressing minority stress and the unique experiences of sexual-minority youths. Alternatively, our findings could reflect unmeasured resilience factors specific to WSWM, such as the development of non–alcohol-related coping mechanisms, that buffer survivors of college sexual assault from using alcohol, though further research is needed to disentangle these mechanisms.
This study also highlighted the salience of sexual assault among women with no penetrative sexual partners; in our study, the relative association between sexual assault and alcohol use was larger for this population. Research is scarce on behavioral outcomes among women who experience sexual assault before they have consensual sex, and further understanding the experiences of these women would improve our approaches to sexual assault prevention on college campuses.
It is important to note that we used a behavioral marker of sexual-minority status in this study. Heterosexual women who have had same-gender partners (“mostly heterosexual” women)32 may be less likely to be the target of prejudice and discrimination compared with women who hold a sexual-minority identity, so classifying them with lesbian and bisexual women may make it more difficult to determine the compounding effects of minority stress and sexual violence on alcohol use. Classifying “mostly heterosexual” women separately from “completely heterosexual” women was an intentional choice, though, considering evidence that this group is more likely than “completely heterosexual” women to report alcohol outcomes.32
There are similar challenges with interpreting findings among women with no penetrative sexual partners. It is possible a woman identified as lesbian, gay, bisexual, or queer and experienced myriad minority stressors (e.g., discrimination from families or peers because of her sexual-minority orientation) without having penetrative sex. Moreover, this category combined women who had sex (just not penetrative sex) and women who had never had sex, and these groups likely have different experiences. Future research would include measures of sexual identity, attraction, and behavior to more completely assess the influence of minority stress on alcohol outcomes.
Limitations
These findings may be considered in light of several limitations. Our study was conducted with cisgender women seeking health services at college health centers in Pennsylvania and West Virginia who agreed to participate in a cluster-randomized trial, which has implications regarding external validity. Specifically, our results may not generalize to noncollege populations, college students who do not seek health care in campus-based health centers, and those who live in regions beyond Pennsylvania or West Virginia. On a related note, our sample demographic characteristics mirrored those of the geographic region resulting in a sample that was predominately White, precluding us from considering statistical interactions of gender of sexual partners, race/ethnicity, and sexual assault history. As there is evidence of race differences in the links between chronic stressors (e.g., sexual assault) and mental health,33 future work on the association between sexual assault and alcohol use should consider the intersection of race/ethnicity and sexual minority status.
We also had a small proportion of WSWM without sexual assault exposure, resulting in potential sparse data bias and wide CIs for some point estimates. In addition, as these data were part of a larger intervention study, we were not able to assess potential confounders such as socioeconomic status and the impact of campus climate or social norms regarding sexual orientation, sexuality, and alcohol use. We used a behaviorally based measure of sexual minority status and, thus, cannot determine whether findings would have been different if we had used sexual identity or sexual attraction measures. Finally, despite recruiting more than 2000 students into the study, we recruited few transgender students and were unable to assess differences in sexual assault and alcohol use among gender-diverse populations.
Public Health Implications
Sexual assault is prevalent among students seeking care in college health centers. Previous research has found that some survivors of sexual violence use alcohol to cope with the trauma.6 However, in this care-seeking sample, we found that the relative association between sexual assault and alcohol use was different for different groups of women. Specifically, this association was smaller for WSWM and larger for women who had no lifetime sexual partners, compared with WSM. These findings underscore the potential role of college health centers in comprehensive sexual violence prevention and intervention efforts on college campuses because they serve a high-risk population. Clinical interventions that normalize conversations about sexual violence and create spaces for women to disclose their sexualities, their sexual histories, and their alcohol use may be a strategy to shift broader, community-level norms about these aspects of identity, behavior, and experience.34
ACKNOWLEDGMENTS
The parent study was funded by the National Institute on Alcohol Abuse and Alcoholism (grant R01AA023260).
Note. The study sponsors had no influence on study design, data collection, analysis, interpretation, article preparation, or decision to submit for publication.
CONFLICTS OF INTEREST
The authors report no conflicts of interest.
HUMAN PARTICIPANT PROTECTION
Study procedures were approved by the Human Research Protections Office at University of Pittsburgh and each participating college’s institutional review board.
Footnotes
See also Blosnich and Goldbach, p. 761.
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