Abstract
Purpose:
To examine the association between sexual minority status and the prevalence of emotional distress and substance use among a nationally-representative sample of youth who reported sexual violence victimization.
Methods:
Data were from the 2017 National Youth Risk Behavior Survey, a biennial school-based survey. We restricted the sample to youth who reported any past-year sexual violence victimization. We estimated prevalence ratios using modified Poisson regression with robust error variance to examine associations of sexual minority status with depressive symptomology, suicidality, and substance use.
Results:
Among the 1364 (9.7%) students who experienced sexual violence, 78% were girls. Relative to heterosexual youth, sexual minority youth had higher prevalence estimates for the emotional distress outcomes and marijuana use. Sexual minority status was associated with depressive symptomology (adjusted prevalence ratio [aPR] 1.33, 95% confidence interval 1.22–1.44), suicidal ideation (aPR: 1.91, 1.66–2.20), medically treated suicide attempt (aPR: 2.74, 1.53–4.93), and past 30-day marijuana use (aPR: 1.29, 1.06–1.57).
Conclusions:
Among youth who experience sexual violence, sexual minorities may experience more emotional distress and substance use outcomes than heterosexuals. Rape crisis programs and other tertiary interventions should attend to the unique needs of sexual minorities who have been sexually victimized.
Keywords: Sexual minority youth, Youth Risk Behavior Survey, Mental health, Emotional distress, Substance use
Introduction
Sexual minority youth (i.e., those who identify as lesbian, gay, or bisexual, or who report same-sex sexual behavior) are more likely than heterosexuals to experience sexual violence victimization [1–5]. On average, sexual minority youth were 3.8 times more likely to experience sexual abuse than heterosexual youth [6]. In a study among college students, 24.3% of sexual minority students reported experiencing sexual assault compared to 11.0% of non-sexual minority students [3]. Furthermore, sexual minority youth are more likely to experience other forms of victimization, such as at-school bullying, online bullying, parental abuse, and dating violence [3,7,8].
Sexual minority youth are also at higher risk for mental health problems, including depression and depressive symptoms, suicidal ideation, suicide attempts, and substance use [9–12]. For example, men who have sex with men with lifetime experience of sexual assault were 2.9 times as likely to abuse alcohol, 3.3 times as likely to attempt suicide, and 6.4 times as likely to have depression compared to those who did not experience sexual assault [11]. A large body of research suggest that mental health disparities stem from social isolation, social stigma, and parental rejection behaviors [13–15]. Sexual minority youth are also more likely to experience problem substance use, although patterns are more nuanced than for mental health problems. For example, the prevalence of substance use is higher for sexual minority girls compared to heterosexual girls, whereas the prevalence of use is somewhat similar among sexual minority and heterosexual boys [16,17].
Studies conducted among adults that examined sexual minority status, victimization, and emotional distress and substance use outcomes suggest that sexual minorities experience more severe victimization [18] and more adverse outcomes [18–20] compared to non-sexual minorities. Although it is well-established that sexual minorities are more likely to experience sexual violence victimization [1–6] and sexual violence victimization is associated with emotional distress and substance use [9–12], it is not clear whether sexual minority youth who have been victimized experience more severe mental health outcomes than their heterosexual counterparts. Furthermore, most studies examining sexual victimization and mental health outcomes among young people have examined college students, and research is more limited in younger age groups [1,2,21,22]. To address this question, we examined emotional distress, suicidality, and substance use among youth who have experienced sexual victimization, comparing sexual minority to heterosexual youth. Elucidating this issue is important for considering whether unique approaches for supporting sexual minority youth cope with sexual victimization are needed.
The purpose of our study was to investigate the association between indicators of emotional distress and substance use among heterosexual and sexual minority high school adolescents who experienced sexual violence victimization. Emotional distress and substance use represent serious problems that victimized sexual minority adolescents face; they can have long-term, adverse effects on health and well-being, especially if not addressed. We leveraged data conducted through the Centers for Disease Control and Prevention’s (CDC’s) National Youth Risk Behavior Survey (YRBS) program. The recent inclusion of items on sexual orientation and sexual violence on the standard questionnaire for the National YRBS provided an opportunity to answer our research question with a nationally-representative sample of high school students. This study illuminates how those associations may vary by sexual minority status, which is imperative for designing substance use prevention and mental health programs for high school students.
Methods
Data source and sample
Data were obtained from the 2017 National YRBS, a survey of United States high school students from grades 9 through 12. The YRBS is a repeated cross-sectional survey, which employs a 3-stage, cluster sample design, where large counties or groups of small counties are assigned as primary sampling units (PSUs) (first stage), schools are selected from PSUs (second stage), and classes are randomly selected from schools (third stage) [23]. The YRBS is administered every 2 years. The YRBS covers topics about adolescent health, including violence, sexual risk behaviors, emotional health, and substance use. The CDC has maintained the YRBS program since 1991 [23,24]. The National YRBS (2017) sample included more than 45,000 students and had an overall response rate of 60%; the student response rate was 81%, and the school response rate was 75%.
The 2017 questionnaire assessed sexual violence victimization with the following question: “During the past 12 months, how many times did anyone force you to do sexual things that you did not want to do? (Count such things as kissing, touching, or being physically forced to have sexual intercourse.)”; response options were 0 times, 1 time, 2 or 3 times, 4 or 5 times, and 6 or more times. We restricted our sample to those who reported that they had experienced any past-year sexual violence.
Sexual minority status
The primary predictor, sexual minority status, was measured with a single item assessing identity: “Which of the following best describes you?” Response options were: heterosexual (straight), gay or lesbian, bisexual, and not sure. Participants who identified as gay or lesbian, or bisexual were classified as sexual minority; those who indicated unsure (n = 98) or who had missing data from this question (n = 57) were excluded from the analytic dataset.
Emotional distress and substance use
We assessed 3 indicators of emotional distress, including depressive symptomology, suicidal ideation, and suicide attempt resulting in injury; all were coded as dichotomous (yes vs. no). Depressive symptomology was based on responses to the following item: “During the past 12 months, did you ever feel so sad or hopeless almost every day for 2 weeks or more in a row that you stopped doing some usual activities?” Suicidal ideation was measured through the following question: “During the past 12 months, did you ever seriously consider attempting suicide?” Suicide attempt resulting in injury was measured through the following question: “If you attempted suicide during the past 12 months, did any attempt result in an injury, poisoning, or overdose that had to be treated by a doctor or nurse?”
Substance use variables included current (i.e., any past 30-day) marijuana use, alcohol use, binge drinking, and extreme binge drinking. Current binge drinking was defined as having 4 or more drinks of alcohol in a row (for girls) or 5 or more drinks of alcohol in a row (for boys) on at least 1 day in the past 30 days, and extreme binge drinking was having 10 or more drinks in a row at least once in the past 30 days.
Covariates
Three demographic variables were used as covariates in this analysis: sex (male or female), grade (9th grade, 10th grade, 11th grade, 12th grade), and race/ethnicity. Categories for race/ethnicity included White, non-Hispanic; Black, non-Hispanic; Hispanic/Latino, any race; and Other, which includes youth who identify as Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, or as being in more than one race group (i.e., multiracial). Those with missing data on sex, race/ethnicity, or grade level were excluded from multivariate models.
Statistical analysis
Characteristics of the study sample were presented using counts and weighted percentages. We used modified Poisson regression models with robust error variance to estimate unadjusted and adjusted prevalence ratios (PRs) and 95% confidence intervals (CIs) to examine associations of sexual minority status with emotional distress/suicidality and substance use. We also presented results from regression models adjusted for race/ethnicity and grade, which sex were included as covariates or stratified by sex. All analyses were conducted using Stata 15 (College Station, TX), and accounted for the survey sampling design.
Results
The analytical sample included 1364 students who reported any past-year sexual violence victimization. More than three-quarters were female (77.9%), 54.6% were White, and all 4 grades were evenly distributed (Table 1). Four percent identified as lesbian or gay, 19.3% as bisexual, and 7.0% as unsure of their sexual orientation.
Table 1.
Descriptive characteristics of high school students who experienced sexual violence, national YRBS, US 2017
| Variables | N (weighted %) |
||||
|---|---|---|---|---|---|
| All groups (N = 1364) | Heterosexual (N = 958) | Lesbian/gay (N = 67) | Bisexual (N = 241) | Unsure* (N = 98) | |
| Sex | |||||
| Male | 334 (22.1%) | 236 (21.5%) | 38 (59.8%) | 29 (14.2%) | 31 (28.6%) |
| Female | 1006 (77.9%) | 712 (78.5%) | 26 (40.2%) | 205 (85.8%) | 63 (71.4%) |
| Missing | 24 | 10 | 3 | 7 | 4 |
| Grade | |||||
| 9th grade | 356 (25.6%) | 256 (26.2%) | 14 (22.9%) | 59 (23.0%) | 27 (29.0%) |
| 10th grade | 348 (26.2%) | 229 (23.3%) | 20 (41.8%) | 73 (35.2%) | 26 (20.8%) |
| 11th grade | 337 (25.3%) | 234 (25.8%) | 21 (24.5%) | 60 (24.9%) | 22 (22.1%) |
| 12th grade | 297 (22.3%) | 224 (24.6%) | 10 (10.8%) | 46 (16.0%) | 17 (24.7%) |
| Ungraded or other grade* | 10 (0.6%) | 4 (0.2%) | 0 (0%) | 2 (0.9%) | 4 (3.4%) |
| Missing | 16 | 11 | 2 | 1 | 2 |
| Race/ethnicity | |||||
| White | 591 (54.6%) | 420 (54.1%) | 22 (37.8%) | 114 (61.7%) | 35 (48.8%) |
| Black | 235 (11.8%) | 162 (10.4%) | 14 (31.7%) | 38 (10.7%) | 21 (18.9%) |
| Hispanic | 99 (6.9%) | 67 (6.9%) | 3 (4.2%) | 20 (7.1%) | 9 (8.7%) |
| Other† | 397 (26.7%) | 285 (28.7%) | 22 (26.3%) | 63 (20.5%) | 27 (23.6%) |
| Missing | 42 | 24 | 6 | 6 | 6 |
YRBS = Youth Risk Behavior Survey.
Coded as missing for statistical analysis.
Other included American Indian/Alaska Native, Asian, and Native Hawaiian or Other Pacific Islander.
Emotional distress and substance use among sexual minority and heterosexual youth are presented in Table 2. Among this sample of US high school students who reported past-year sexual victimization, 14% (n = 271) reported at least one emotional distress outcome and 13% (n = 185) reported at least one substance use outcome. Relative to heterosexual students, sexual minority students were significantly more likely to report depressive symptomology (adjusted PR: 1.33, 95% CI: 1.22, 1.44), considering suicide (adjusted PR: 1.91, 95% CI: 1.66, 2.20), injurious suicide attempt (adjusted PR: 2.74, 95% CI: 1.53, 4.93). The prevalence was higher among sexual minority versus heterosexual students for marijuana use (adjusted PR: 1.29, 95% CI: 1.06, 1.57), but not for any of the alcohol use variables.
Table 2.
Unadjusted and adjusted Poisson regression models examining the associations between sexual minority status and mental health problems among high school students who experienced sexual violence, national YRBS, US 2017
| Outcomes | Heterosexual students* (N = 958) |
Sexual minority students* (N = 308) |
Prevalence ratios |
||||||
|---|---|---|---|---|---|---|---|---|---|
| Total N† | N with outcome | P | Total N† | N with outcome | P | PR (95% CI) | aPR‡ (95% CI) | ||
| Emotional distress | Depression symptoms | 944 | 551 | 60% | 299 | 238 | 79% | 1.31 (1.21, 1.43) | 1.33 (1.22, 1.44) |
| Considered suicide | 943 | 334 | 36% | 299 | 198 | 67% | 1.86 (1.63, 2.13) | 1.91 (1.66, 2.20) | |
| Injurious suicide attempt | 662 | 49 | 7% | 217 | 41 | 16% | 2.50 (1.47, 4.27) | 2.74 (1.53, 4.93) | |
| Substance use | Marijuana use | 935 | 303 | 34% | 284 | 118 | 43% | 1.26 (1.04, 1.52) | 1.29 (1.06, 1.57) |
| Alcohol use | 803 | 392 | 51% | 242 | 131 | 51% | 1.00 (0.85, 1.16) | 0.99 (0.84, 1.16) | |
| Binge drinking | 851 | 217 | 26% | 264 | 74 | 27% | 1.03 (0.80, 1.33) | 1.05 (0.81, 1.38) | |
| Consumed ≥ 10 drinks | 588 | 42 | 7% | 186 | 15 | 8% | 1.07 (0.57, 2.01) | 1.33 (0.64, 2.76) | |
aPR = adjusted prevalence ratio; CI = confidence interval; N = number of observations; P = weighted prevalence of outcome; PR = prevalence ratio; YRBS = Youth Risk Behavior Survey.
Exposure: Sexual minority status vs. heterosexual.
The total number of observations with nonmissing values for each outcome.
Adjusted for sex, race, and grade.
Findings in sex-stratified regression models were slightly different (Table 3). Sexual minority girls had a much higher prevalence of reporting depressive symptomology (girls: 86%, boys: 56%) and considering suicide (girls: 73%, boys: 45%) compared to sexual minority boys. The association between sexual minority status with depression symptoms and suicidal attempt held for boys and girls, the association between sexual minority status and injurious suicide attempt held only for girls, and the association between sexual minority status and marijuana use did not hold for girls or boys. Sexual minority boys were more likely to report any past 30-day alcohol use (adjusted PR: 1.38, 95% CI: 1.01, 1.90); there were no other statistically significant associations between sexual minority status and substance use among girls or boys.
Table 3.
Sex-stratified unadjusted and adjusted Poisson regression models examining the associations between sexual minority status and mental health problems among high school students who experienced sexual violence, national YRBS, US 2017
| Boys | Outcomes | Heterosexual boys* (N = 236) |
Sexual minority Boys* (N = 67) |
Prevalence ratios |
|||||
|---|---|---|---|---|---|---|---|---|---|
| Total N† | N with outcome | P | Total N† | N with outcome | P | PR (95% CI) | aPR‡ (95% CI) | ||
|
| |||||||||
| Emotional distress | Depression symptoms | 232 | 104 | 44% | 61 | 42 | 56% | 1.27 (0.84, 1.93) | 1.55 (1.10, 2.18) |
| Considered suicide | 228 | 73 | 33% | 62 | 30 | 45% | 1.37 (0.90, 2.08) | 1.77 (1.18, 2.64) | |
| Injurious suicide attempt | 132 | 13 | 10% | 34 | 7 | 14% | 1.49 (0.57, 3.87) | 2.68 (0.78, 9.29) | |
| Substance use | Marijuana use | 221 | 81 | 43% | 54 | 22 | 53% | 1.24 (0.88, 1.75) | 1.32 (0.97, 1.79) |
| Alcohol use | 184 | 81 | 45% | 39 | 25 | 60% | 1.35 (0.90, 2.02) | 1.38 (1.01, 1.90) | |
| Binge drinking | 206 | 51 | 29% | 47 | 15 | 33% | 1.13 (0.51, 2.49) | 1.36 (0.75, 2.49) | |
| Consumed ≥ 10 drinks | 138 | 19 | 19% | 26 | 6 | 21% | 1.08 (0.45, 2.60) | 1.27 (0.55, 2.94) | |
|
| |||||||||
| Girls | Outcomes | Heterosexual girls* (N = 712) |
Sexual minority Girls* (N = 231) |
Prevalence ratios |
|||||
| Total N† | N with outcome | P | Total N† | N with outcome | P | PR (95% CI) | aPR‡ (95% CI) | ||
|
| |||||||||
| Emotional distress | Depression symptoms | 703 | 440 | 65% | 229 | 188 | 86% | 1.32 (1.21, 1.44) | 1.31 (1.20, 1.43) |
| Considered suicide | 706 | 256 | 37% | 228 | 161 | 73% | 1.98 (1.75, 2.25) | 1.98 (1.73, 2.26) | |
| Injurious suicide attempt | 524 | 34 | 6% | 178 | 31 | 16% | 2.77 (1.34, 5.72) | 2.76 (1.34, 5.68) | |
| Substance use | Marijuana use | 705 | 216 | 32% | 220 | 91 | 40% | 1.26 (0.98, 1.62) | 1.27 (0.98, 1.64) |
| Alcohol use | 614 | 306 | 53% | 194 | 100 | 48% | 0.91 (0.73, 1.12) | 0.91 (0.73, 1.13) | |
| Binge drinking | 639 | 163 | 25% | 208 | 56 | 25% | 1.00 (0.69, 1.44) | 0.99 (0.68, 1.43) | |
| Consumed ≥ 10 drinks | 445 | 22 | 4% | 155 | 8 | 5% | 1.19 (0.45, 3.15) | 1.15 (0.40, 3.33) | |
aPR = adjusted prevalence ratio; CI = confidence interval; N = number of observations; P = weighted prevalence of outcome; PR = prevalence ratio; YRBS = Youth Risk Behavior Survey.
Exposure: Sexual minority status versus heterosexual.
The total number of observations with nonmissing values for each outcome.
Adjusted for race and grade.
Discussion
Among a nationally-representative sample of high school students who reported past-year sexual violence victimization, we investigated whether sexual minority youth were more likely than heterosexual youth to experience emotional distress and to use marijuana and alcohol, and whether the association differed by sex. Sexual minority boys were more likely than heterosexual boys to report past year depressive symptoms, suicidal ideation, and past 30-day alcohol use; whereas sexual minority girls were more likely than heterosexual girls to report past year depressive symptoms, suicidal ideation, and injurious suicide attempt. In sex-pooled samples, sexual minority status was associated with a higher prevalence of all 3 indicators of emotional distress (i.e., depressive symptoms, suicidal ideation, and injurious suicide attempt) and past 30-day marijuana use, but not with any of the 3 alcohol use variables (i.e., past 30-day use, binge drinking, and extreme binge drinking).
Our study suggests that among youth who experienced sexual violence, identifying as a sexual minority has a stronger association with emotional distress compared to identifying as heterosexual, and also that this link may not be as strong for marijuana and alcohol use. The weaker associations for substance use could relate to the high prevalence of alcohol and marijuana use among adolescents. Our findings on emotional distress are consistent with prior literature. Some studies have shown that LGBTQ (lesbian, gay, bisexual, transgender, and questioning or queer) youth who experienced peer victimization (e.g. at-school or online teasing or bullying) reported suicidal ideation and attempts at higher rates than their heterosexual counterparts who were similarly victimized [7,8,25]. Those previous studies examining LGBTQ disparities in suicidality focus on bullying and other forms of peer victimization. Our findings suggest that experience of sexual violence is also a key consideration for future research on suicidality among LGBTQ adolescents.
There are several reasons that sexual minority youth would be more likely to experience distress following sexual victimization as compared to heterosexual youth. Sexual minority youth may have experienced more severe or more frequent victimization [7,26]. There could be other key differences in the victimization [27]; for example, they may have been targeted for assault because of the sexual minority status or gender presentation. Additionally, sexual minority youth may have fewer psychosocial resources to cope with violence, such as limited parental support or victim services being ill-equipped to work with sexual minorities [28]. Finally, the emotional toll of sexual violence could be greater as they navigate the stigmatizing structural and social environments of sexual diversity [29].
A major strength of this analysis is that our findings are nationally representative of high school students in the US. We also used rich data about a variety of emotional distress and substance use variables. One limitation is that variables were not available for gender identity or chronicity of sexual violence, timing, who the perpetrator was, other forms of violence that youth experienced, or support received afterward. Second, since sexual victimization was self-reported and is a sensitive topic, it is possible that there was underreporting for this variable. Third, because of the small sample size of sexual minority youth in our analytical sample, we combined all sexual minority youth in our analysis; future studies should oversample sexual minority youth to capture the more nuanced experiences between different LGBTQ groups. Fourth, because this survey was cross-sectional, we could not evaluate the temporal relationship between sexual minority status and adverse mental health and substance use outcomes. Lastly, we noted that sexual minority youth experience polyvictimization; in this study, we only examined youth who experience one form, sexual victimization.
Overall, our study findings suggest that adolescent sexual minorities who experienced sexual violence reported experiencing higher proportions of a range of emotional distress/suicidality outcomes compared to heterosexual adolescents. This indicates the necessity of specifically designed health programs to support this population. More resources and professional services should be directed at those who experienced victimization to assess emotional distress and substance use. Professional training and consultations should be provided to counselors and organizations in models and approaches that incorporate inclusiveness and affirmative support for sexual minorities [27]. These approaches should consider the experience of sexual violence among sexual minorities as well as the lack of resources and social support needed for recovery. Nevertheless, more efforts should concentrate on primary prevention of sexual abuse to provide an effective prevention program that identifies the best evidence-based practices [30]. There is an urgent need to address the mental health impact of sexual violence in sexual minority youth. Future research should conduct longitudinal analyses to look at time trends in outcomes and care-seeking behaviors. This would enhance our understanding of excess risk behaviors among this population and guide appropriate intervention programs.
Acknowledgments
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. KEL was supported by the National Institute of Drug Abuse through K01DA048174 (Lancaster, PI).
Abbreviation:
- YRBS
Youth Risk Behavior Survey
- CDC
Centers for Disease Control and Prevention
- PR
prevalence ratio
- aPR
adjusted prevalence ratio
- N
number of observations
- P
weighted prevalence of outcome
- CI
confidence interval
Footnotes
The authors have no conflicts of interest to disclose.
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