Sexual identity, child maltreatment, mental health, and substance use among emerging adults aged 18 to 23 years
Department of Community Health Sciences, University of Manitoba, Winnipeg, MB Canada
Department of Psychiatry, University of Manitoba, Winnipeg, MB Canada
Faculty of Social Work, University of Manitoba, Winnipeg, MB Canada
Abstract
Objectives
Although past studies have identified sex differences in child maltreatment experiences and poor mental and physical health‒related outcomes, more research is needed to understand child maltreatment among sexual minorities (i.e., those who identify as other than heterosexual) and how child maltreatment and sexual identity are related to depression, anxiety, and at-risk alcohol and cannabis use among emerging adults.
Methods
Data were drawn from the longitudinal Well-Being and Experiences (WE) Study collected from 2017 (14 to 17 years) to 2022 (18 to 23 years) from Manitoba, Canada (n = 584). Descriptive statistics and logistic regression models were computed.
Results
Compared to heterosexual or straight sexual identity: homosexual, gay or lesbian; bisexual; and different or other identity were associated with an increased likelihood of experiencing child maltreatment, with the most robust relationships for bisexual identity and all child maltreatment outcomes. Indicating “I don’t know” for sexual identity compared to heterosexual identity was associated with 7.45 increased odds of exposure to intimate partner violence in adjusted models. Bisexual identity compared to heterosexual identity had the most robust association, with increased odds of depression, anxiety, at-risk alcohol use, and at-risk cannabis use. Findings provide some evidence to suggest that trends may be worse for some mental health and substance use outcomes among sexual minorities who also experience child maltreatment.
Conclusion
Preventing child maltreatment among all children, including youth identifying as other than heterosexual, is a public health priority. Such efforts will work towards optimizing mental health and reducing substance use in early adulthood.
Untitled section
Keywords: Sexual identity, Sexual orientation, Child maltreatment, Depression, Anxiety, Cannabis, Alcohol, Substance use
Résumé
Objectifs
Des études antérieures ont constaté des différences entre les sexes dans les expériences de maltraitance des enfants et les problèmes de santé mentale et physique qui en résultent, mais il faut pousser la recherche pour comprendre la maltraitance des enfants chez les minorités sexuelles (c.-à-d. les personnes qui s’identifient autrement que comme étant hétérosexuelles) et les liens entre la maltraitance des enfants et l’identité sexuelle, d’une part, et la dépression, l’anxiété et la consommation à risque d’alcool et de cannabis chez les adultes en émergence.
Méthode
Les données proviennent de l’étude longitudinale Well-Being and Experiences (WE); elles ont été recueillies entre 2017 (14 à 17 ans) et 2022 (18 à 23 ans) au Manitoba (Canada) (n = 584). Des statistiques descriptives et des modèles de régression logistique ont été employés.
Résultats
Comparativement à l’identité hétérosexuelle (hétéro): l’identité homosexuelle, gaie ou lesbienne, l’identité bisexuelle et les identités différentes ou autres étaient associées à une probabilité accrue d’avoir connu la maltraitance durant l’enfance; les relations les plus robustes ont été observées pour l’identité bisexuelle et pour tous les résultats de maltraitance des enfants. La réponse «Je ne sais pas» à la question sur l’identité sexuelle, comparativement à l’identité hétérosexuelle, était associée à une probabilité d’exposition à la violence entre partenaires intimes accrue de 7,45 dans les modèles ajustés. L’identité bisexuelle, comparativement à l’identité hétérosexuelle, présentait l’association la plus robuste avec les probabilités accrues de dépression, d’anxiété, de consommation d’alcool à risque et de consommation de cannabis à risque. Les constats de l’étude donnent à penser que les tendances peuvent être pires pour certains résultats de santé mentale et de consommation de substances chez les minorités sexuelles ayant aussi connu la maltraitance durant l’enfance.
Conclusion
La prévention de la maltraitance chez tous les enfants, y compris les jeunes s’identifiant autrement que comme étant hétérosexuels, est un besoin prioritaire en santé publique. Une telle démarche contribuera à optimiser la santé mentale et à réduire la consommation de substances au début de l’âge adulte.
Article notes
Untitled section
Received 2024 Jun 28; Accepted 2024 Dec 18; Collection date 2025 Oct.
Introduction
Child maltreatment (i.e., child abuse and neglect) remains an important public health problem that can have a negative impact on health, substance use, criminal behaviour, and risky sexual behaviour across the lifespan (Gilbert et al., 2009). Child maltreatment includes experiences of physical abuse, sexual abuse, emotional abuse, emotional neglect, physical neglect, and exposure to intimate partner violence (EIPV). It is estimated that every year, millions of children are abused and neglected worldwide (World Health Organization, 2014; World Health Organization et al., 2006). In Canada, 32% of adults in the general population retrospectively reported having experienced physical abuse, sexual abuse, and/or EIPV in childhood (Afifi et al., 2014). When child maltreatment occurs, the odds of having substance use problems, mental disorders, and thinking about or attempting suicide increase (Afifi et al., 2011, 2012a, 2013, 2014, 2017a, 2020b; Anda et al., 2002; Dube et al., 2002; Felitti et al., 1998; Merrick et al., 2017). Although advances have been made in understanding the impact of child maltreatment, several gaps in knowledge remain, including a lack of understanding of these associations among individuals with diverse sexual identities.
Research has shown that sex differences (i.e., biological attributes and sex assigned as male or female at birth) exist in relation to the prevalence of different child abuse types in Canada, with males (31%) being more likely to experience physical abuse than females (21.3%), and females (14.4%) being more likely to experience sexual abuse than males (5.8%) (Afifi et al., 2014). In addition to sex differences in the prevalence of child abuse types, sex differences are noted in the literature related to relationships between child maltreatment and poor mental and physical health outcomes, including substance use during adolescence (Benedini & Fagan, 2020; Salmon et al., 2022) and into adulthood (Afifi et al., 2012b, 2017b; Gallo et al., 2018; MacMillan et al., 2001; Ruiz & Font, 2020; Scott et al., 2023; Soares et al., 2020).
Although several studies have included sex differences when examining the relationships between child maltreatment and mental health and substance use, fewer studies have examined how sexual orientation or sexual identity may be related to child maltreatment. Sexual orientation refers to emotional, physical, romantic, sexual or spiritual attraction; desire; or affection for another person (GLAAD, n.d.; Pinto et al., 2019). In this study, we use the term sexual identity to refer to how an individual identifies their sexual orientation. Sexual minorities are those who identify as other than heterosexual. Previous research using nationally representative Canadian data of youth aged 15 to 17 years collected in 2019 indicated that 78.6% identified as heterosexual, 0.8% identified as boys attracted to boys, 1.0% identified as girls attracted to girls, 14.7% identified as attracted to more than one gender, 0.6% identified as transgender, and 4.3% identified as not sure about sexual attraction (Kingsbury et al., 2022). Research indicates that adults and youth identifying with a sexual identity other than heterosexual report elevated levels of adverse childhood experiences (ACEs), including child abuse and neglect (Afifi et al., 2012b; Andersen & Blosnich, 2013; Austin et al., 2016; Clements-Nolle et al., 2018; Craig et al., 2020; Friedman et al., 2011; Schnarrs et al., 2019; Tran et al., 2023). For example, women who identify as lesbian, bisexual, or gay have reported high levels of child physical and sexual abuse (Morris & Balsam, 2003). Parental acceptance and rejection theories that may impact parent–child attachment have been used to understand why sexual minority youth born to heterosexual parents may be at-risk for violence (Katz-Wise et al., 2016). For some youth, expressing sexual identity that is other than heterosexual may create negative parental responses that may lead to anxiety for the child, future abuse, or banishment from the home (Katz-Wise et al., 2016). In addition, previous research has indicated that anxiety, depression, suicide attempts, and substance use are elevated among youth and adults who identify as gay, lesbian, or bisexual in comparison to heterosexual (Depa et al., 2022; Krueger et al., 2022; McCabe et al., 2022; Morris & Balsam, 2003), with some studies indicating that bisexual individuals have the most elevated associations (Chan et al., 2020; Charak et al., 2019; Friedman et al., 2011; McCabe et al., 2022).
The current literature on sexual identity and mental health and substance use outcomes remains limited for several reasons. First, as previously mentioned, most studies look at sex differences and not sexual identity differences. Second, research that includes sexual identity often uses undergraduate samples or crowdsourcing (Balsam et al., 2010; Charak et al., 2019; Craig et al., 2017; Jiang et al., 2023). Third, some studies do not use validated measures of child maltreatment, mental disorders, and/or substance use (Andresen et al., 2022; Schnarrs et al., 2019). Fourth, it can be common for studies to only include one type of child maltreatment, such as sexual abuse (McCabe et al., 2022). The inclusion of emotional abuse, emotional neglect, and physical neglect is less common in this literature. While these data on sexual abuse are still important and useful, understanding experiences more widely, including other types of child maltreatment, is needed. Fifth, adjusting for sociodemographic covariates, including sex, age, household income, and ethnicity, is important for understanding the independent relationship between sexual identity and mental health and substance use outcomes. Finally, more research in this area is necessary among youth and emerging adults since studies often use adult-only samples with wide age ranges (Andresen et al., 2022; Friedman et al., 2011; Tran et al., 2022). It is important to better understand the relationships between sexual identity and child maltreatment experiences among youth and emerging adults, and to examine whether child maltreatment histories appear to worsen mental health and substance use outcomes.
To address these knowledge gaps, the aims of the current study were to (1) compute the prevalence of sexual identity in a community sample of young emerging adults; (2) determine the associations between sexual identity and increased likelihood of experiencing child maltreatment, including physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect, and EIPV; (3) determine the associations between sexual identity and increased likelihood of depression, anxiety, and at-risk alcohol and cannabis use; and (4) examine whether child maltreatment histories moderate the relationships between sexual identity and depression, anxiety, and at-risk alcohol and cannabis use or whether trends in the relationships between sexual identity and mental disorders and substance use appear to be worse for emerging adults with a child maltreatment history.
Methods
Data and sample
Data were drawn from the longitudinal Well-Being and Experiences (WE) Study collected from 2017 to 2022 using individual self-administered computerized surveys in Manitoba, Canada. The overall purpose of the WE Study was to learn more about the health, well-being, and experiences of youth, parents, and families in Manitoba. The intended population for the WE Study was youth aged 14 to 17 years along with a parent or caregiver. Convenience sampling (i.e., referrals and community advertisements; 79%) and random digit dialing (21%) were used to recruit respondents. During baseline data collection, demographic variables, including sex, household income, and ethnicity, were monitored to ensure the sample resembled the province’s general population (Statistics Canada, 2017). For the current study, data were from waves 1, 3, 4, and 5 (n = 584, 58% retained from baseline in 2017). No data from wave 2 were required for the current study. Adolescents were 14 to 17 years old at wave 1 in 2017–2018 and were 18 to 23 years old at wave 5. Wave 1 questionnaires were completed in person in private rooms using an online survey at a research facility. Waves 3–5 questionnaires were completed using an emailed link to an online survey. Informed consent was provided at all waves. Ethics approval was obtained from the Health Research Ethics Board at the University of Manitoba. Additional information about the WE Study has been previously published (Afifi et al., 2020a, 2020b; Fortier et al., 2022).
Measurement
Sexual identity
Respondents were asked to indicate their current sexual identity at waves 4 and 5. Response options included (a) heterosexual or straight; (b) homosexual, gay, or lesbian; (c) bisexual; (d) other identity (please specify); (e) I don’t know; and (f) no response. Answers at wave 5 (in 2022) were used in this study to measure sexual identity. For individuals who did not participate in wave 5, information on sexual identity provided in wave 4 was used. Thirty-two of the respondents specified their identities (verbatim), which included asexual, asexual and aromantic, pansexual, pansexual and polyamorous, pansexual/demisexual, queer/questioning, queer/asexual spectrum/bisexual or pansexual (uncertain), heterosexual-omniromantic, unidentified, and unlabeled. These identities could not be examined individually due to low frequency and were therefore combined as other identity.
Child maltreatment
Childhood physical abuse, sexual abuse, emotional abuse, physical neglect, and emotional neglect were measured using the Childhood Trauma Questionnaire (CTQ), which included five items for each type of abuse or neglect (Bernstein & Fink, 1998). EIPV was assessed using an adapted item from the Childhood Experiences of Violence Questionnaire (CEVQ), asking the respondents whether, before age 16 years, they heard a parent, step-parent, or guardian hit each other or another adult in their home (Walsh et al., 2008). Complete child maltreatment information was collected in waves 3, 4, and 5 when the respondent was 18 years old. Any child maltreatment was coded as having experienced one or more of the above types of abuse and/or neglect.
Depression and anxiety
The 9-item Patient Health Questionnaire (PHQ-9) was used to assess depression symptoms at waves 3, 4, and 5. Anxiety symptoms were assessed using the 7-item General Anxiety Disorder (GAD-7). For both instruments, respondents rated how bothered they had been by certain problems over the past 2 weeks based on a 4-point scale. A probable diagnosis of depression or anxiety being clinically significant at any of the three waves was coded with a summed score of 10 or more (Kroenke et al., 2010; Manea et al., 2015).
At-risk alcohol use and at-risk cannabis use
At-risk alcohol use was assessed using the Alcohol Use Disorders Identification Test (AUDIT) at waves 3, 4, and 5. At-risk cannabis use was assessed using the Cannabis Use Disorder Identification Test–Revised (CUDIT-R) at waves 3, 4, and 5. The AUDIT is a 10-item instrument psychometrically validated that assesses past-year alcohol use, with most questions rated on a 5-point scale (Babor et al., 2001; Saunders et al., 1993). The CUDIT-R is an eight-item revised and psychometrically validated version of the original CUDIT instrument that assesses past 6-month cannabis use, with the majority of questions also rated on a 5-point scale (Adamson et al., 2010). While earlier work suggests a score of eight or more to assess at-risk alcohol use (Babor et al., 2001; Saunders et al., 1993), a number of recent studies testing AUDIT psychometrics among younger populations of adolescents and/or young adults (primarily college or university students) recommend using a lower cut-off score (Cortés-Tomás et al., 2016; Coulton et al., 2019; Kokotailo et al., 2004; Liskola et al., 2018; Reichenheim et al., 2021). Given the age range in our sample, we decided to lower the cut-off score to six or more to assess at-risk alcohol use, as has been used in a previous study of university students in the United States (Kokotailo et al., 2004). Similarly, a cut-off score of six or more was used to assess at-risk cannabis use, based on the recommendation by Schultz et al. (2019).
Covariates
Sex at birth (i.e., male or female), age in years, youth ethnicity (i.e., white only, white and another ethnicity, or other/multi-ethnicity), and household income reported by parents at wave 1 (i.e., $49,999 or less, $50,000 to $99,999, $100,000 to $149,999, and $150,000 or more) were included as covariates in adjusted models.
Statistical analysis
First, descriptive statistics were conducted. Next, logistic regression models were run between sexual identity and (a) each child maltreatment type, (b) depression, (c) anxiety, (d) at-risk alcohol use, and (e) at-risk cannabis use. Models were first run unadjusted and then adjusted for sex, age, ethnicity, and household income. Finally, multiplicative interaction effect models were computed to determine whether child maltreatment moderated (i.e., worsened) the relationships between sexual identity and (a) depression, (b) anxiety, (c) at-risk alcohol use, and (d) at-risk cannabis use. As a post hoc examination, logistic regressions were conducted stratified by child maltreatment (i.e., those with and without a child maltreatment history) to examine whether trends appear worse among those with a child maltreatment history. Three levels of p values are provided for the logistic regression models at * p ≤ 0.05; ** p ≤ 0.01; *** p ≤ 0.001 so that one can interpret statistical significance at more conservative levels if desired.
Results
Among the sample, 70.6% identified as heterosexual; 2.6% as homosexual, gay, or lesbian; 19.5% as bisexual; 3.9% as other identity; and 3.4% as indicating “I don’t know”. Table 1 presents the prevalence of sex, household income, and age by sexual identity.
| Total sample | Heterosexual or straight | Other identity | |
|---|---|---|---|
| Sociodemographic | (%) | (%) | (%) |
| Biological sex (from wave 1) | |||
| Male | (43.89) | (51.34) | (25.88) |
| Female | (56.11) | (48.66) | (74.12) |
| Household income (parent reported at wave 1) | |||
| $49,999 or less | (15.41) | (12.72) | (21.82) |
| $50,000 to $99,999 | (38.17) | (37.91) | (38.79) |
| $100,000 to $149,999 | (23.66) | (26.46) | (16.97) |
| $150,000 or more | (22.76) | (22.90) | (22.42) |
| Age (at wave 5) | |||
| 18 | (11.20) | (10.14) | (11.63) |
| 19 | (26.72) | (21.62) | (28.81) |
| 20 | (25.93) | (29.73) | (24.38) |
| 21 | (22.59) | (23.65) | (22.16) |
| 22‒23 | (13.56) | (14.86) | (13.02) |
Table 2 presents findings of the relationships for sexual identity and odds of experiencing physical abuse, sexual abuse, emotional abuse, physical neglect, and emotional neglect. Bisexual identity compared to heterosexual identity was associated with an increased likelihood of physical abuse (adjusted odds ratio (AOR) = 2.39, 95% confidence interval (CI) = 1.18–4.82 in the adjusted model), sexual abuse (AOR = 3.66, 95% CI = 2.11–6.32), emotional abuse (AOR = 3.35, 95% CI = 1.97–5.68), physical neglect (AOR = 3.60, 95% CI = 2.02–6.44), and emotional neglect (AOR = 2.89, 95% CI = 1.56–5.36). Other identity, compared to heterosexual identity, was associated with increased odds of experiencing physical neglect (AOR = 3.36, 95% CI = 1.14–9.89). Some type II errors may be indicated in non-significant models with moderate effect sizes and large confidence intervals. As a post hoc sensitivity analysis due to limited statistical power, we dichotomized sexual identity as heterosexual versus all other identities and found that having sexual identities other than heterosexual was associated with an increased likelihood of all five child maltreatment types in the adjusted models (AORs ranging from 1.98 to 3.33).
| Physical abuse | Sexual abuse | Emotional abuse | Physical neglect | Emotional neglect | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| OR (95% CI) | AOR (95% CI) | OR (95% CI) | AOR (95% CI) | OR (95% CI) | AOR (95% CI) | OR (95% CI) | AOR (95% CI) | OR (95% CI) | AOR (95% CI) | |
| Sexual identity (reference group: heterosexual or straight) | ||||||||||
| Homosexual, gay, or lesbian | 1.96 | 1.26 | 2.35 | 1.93 | 3.28* | 2.27 | 3.05 | 3.08 | 4.00* | 3.66 |
| (0.42–9.14) | (0.15–10.60) | (0.62–8.85) | (0.39–9.57) | (1.06–10.12) | (0.56–9.20) | (0.92–10.13) | (0.76–12.46) | (1.19–13.40) | (0.93–14.45) | |
| Bisexual | 2.90*** | 2.39* | 4.42*** | 3.66*** | 4.02*** | 3.35*** | 3.56*** | 3.60*** | 2.98*** | 2.89*** |
| (1.59–5.30) | (1.18–4.82) | (2.68–7.29) | (2.11–6.32) | (2.51–6.43) | (1.97–5.68) | (2.15–5.90) | (2.02–6.44) | (1.70–5.23) | (1.56–5.36) | |
| Other identity | 1.17 | 1.11 | 1.24 | 1.18 | 1.73 | 1.73 | 3.05* | 3.36* | 2.22 | 2.38 |
| (0.26–5.26) | (0.23–5.22) | (0.35–4.34) | (0.33–4.28) | (0.62–4.88) | (0.59–5.11) | (1.13–8.26) | (1.14–9.89) | (0.71–6.92) | (0.74–7.63) | |
| I don’t know | 1.47 | 1.59 | 1.47 | 1.52 | 1.57 | 1.74 | 2.03 | 2.2 | 2.67 | 2.62 |
| (0.32–6.68) | (0.33–7.64) | (0.41–5.23) | (0.41–5.69) | (0.50–4.90) | (0.53–5.65) | (0.65–6.39) | (0.66–7.35) | (0.84–8.46) | (0.79–8.65) | |
| Sensitivity analysis (reference group: heterosexual or straight) | ||||||||||
| Homosexual, gay, or lesbian, bisexual, other, I don’t know | 2.38*** | 1.98* | 3.29*** | 2.82*** | 3.25*** | 2.78*** | 3.25*** | 3.33*** | 2.91*** | 2.84*** |
| (1.37–4.14) | (1.05–3.72) | (2.08–5.21) | (1.71–4.63) | (2.13–4.96) | (1.74–4.45) | (2.06–5.12) | (2.00–5.55) | (1.76–4.81) | (1.65–4.89) | |
Table 3 presents the findings for sexual identity and odds of experiencing EIPV. Indicating “I don’t know” for sexual identity compared to heterosexual was associated with increased odds for EIPV (AOR = 7.45, 95% CI = 1.72–32.34).
| Exposure to verbal intimate partner violence | ||
|---|---|---|
| OR (95% CI) | AOR (95% CI) | |
| Sexual identity (reference group: heterosexual or straight) | ||
| Homosexual, gay, or lesbian | Omitted | Omitted |
| Bisexual | 3.12** | 2.08 |
| (1.33–7.33) | (0.77–5.63) | |
| Other identity | 1.40 | 1.38 |
| (0.17–11.18) | (0.16–11.70) | |
| I don’t know | 5.50* | 7.45** |
| (1.42–21.23) | (1.72–32.34) | |
| Sensitivity analysis (reference group: heterosexual or straight) | ||
| Homosexual, gay, or lesbian, bisexual, other, I don’t know | 2.83** | 2.25 |
| (1.30–6.17) | (0.94–5.41) | |
Table 4 presents the findings of the relationships between sexual identity and mental health and substance use outcomes. Sexual identity of homosexual, gay, or lesbian compared to heterosexual identity was associated with an increased likelihood of depression (AOR = 12.05, 95% CI = 1.50–96.67) and at-risk cannabis use (AOR = 4.67, 95% CI = 1.34–16.20). Bisexual identity, compared to heterosexual identity, was associated with an increased likelihood of depression (AOR = 5.33, 95% CI = 2.81–10.12), anxiety (AOR = 2.07, 95% CI = 1.25–3.43), at-risk alcohol use (AOR = 2.05, 95% CI = 1.25–3.34), and at-risk cannabis use (AOR = 2.67, 95% CI = 1.62–4.41). Other identity, compared to heterosexual identity, was associated with an increased likelihood of depression (AOR = 4.32, 95% CI = 1.22–15.24). Notably, several of these models indicated moderate effect sizes with wide confidence intervals that were not statistically significant, which indicates some underpowered models and a possibility of a type II error.
| Depression | Anxiety | CUDIT | AUDIT | |||||
|---|---|---|---|---|---|---|---|---|
| OR (95% CI) | AOR (95% CI) | OR (95% CI) | AOR (95% CI) | OR (95% CI) | AOR (95% CI) | OR (95% CI) | AOR (95% CI) | |
| Sexual identity (ref: heterosexual or straight) | ||||||||
| Homosexual, gay, or lesbian | 13.15* | 12.05* | 2.34 | 1.76 | 3.10* | 4.67* | 0.80 | 0.69 |
| (1.71–100.97) | (1.50–96.67) | (0.77–7.11) | (0.50–6.17) | (1.08–8.92) | (1.34–16.20) | (0.26–2.48) | (0.19–2.48) | |
| Bisexual | 6.31*** | 5.33*** | 2.87*** | 2.07** | 2.62*** | 2.67*** | 2.05** | 2.05** |
| (3.47–11.45) | (2.81–10.12) | (1.82–4.55) | (1.25–3.43) | (1.67–4.10) | (1.62–4.41) | (1.32–3.19) | (1.25–3.34) | |
| Other identity | 4.23* | 4.32* | 2.02 | 2.09 | 1.55 | 1.97 | 1.04 | 1.25 |
| (1.40–12.72) | (1.22–15.24) | (0.85–4.78) | (0.80–5.46) | (0.64–3.79) | (0.76–5.10) | (0.42–2.58) | (0.48–3.26) | |
| I don’t know | 3.52* | 3.00 | 2.81* | 2.49 | 1.50 | 1.43 | 0.93 | 0.82 |
| (1.15–10.80) | (0.95–9.47) | (1.05–7.56) | (0.89–6.97) | (0.59–3.84) | (0.54–3.83) | (0.36–2.36) | (0.30–2.26) | |
Moderation models were computed and assessed at p value of 0.1 as recommended to reduce a type II error when sample sizes are small (Fairchild & MacKinnon, 2009). None of the models reached statistical significance and, therefore, post hoc logistic regression models were computed stratified by child maltreatment histories to examine overall trends. Table 5 presents the findings for the relationships between sexual identity and depression, anxiety, at-risk alcohol use, and at-risk cannabis use stratified by those with and without a child maltreatment history. Although not statistically compared due to stratified models, trends suggest that sexual identity is related to poor mental health and at-risk substance use for those with and without a child maltreatment history, with some larger effects sizes for homosexual, gay, or lesbian compared to heterosexual individuals for anxiety, at-risk alcohol, and at-risk cannabis use; bisexual compared to heterosexual individuals for depression and anxiety; and those indicating “I don’t know” for sexual identity compared to heterosexuals for at-risk alcohol use.
| Depression | Anxiety | At-risk cannabis | At-risk alcohol | |||||
|---|---|---|---|---|---|---|---|---|
| OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | |||||
| Any child maltreatment | ||||||||
| Sexual identity (ref: heterosexual or straight) | No | Yes | No | Yes | No | Yes | No | Yes |
| Homosexual, gay, or lesbian | 7.78 | Omitted | 1.45 | 3.06 | 3.45 | 3.67 | 0.27 | 1.65 |
| (0.92–65.57) | (0.32–6.61) | (0.35–27.02) | (0.75–15.82) | (0.68–19.73) | (0.03–2.32) | (0.35–7.70) | ||
| Bisexual | 2.98** | 8.16*** | 1.50 | 2.28* | 2.43* | 1.99* | 2.06 | 1.85* |
| (1.36–6.53) | (2.77–24.05) | (0.71–3.16) | (1.15–4.51) | (1.16–5.10) | (1.07–3.69) | (0.98–4.32) | (1.01–3.39) | |
| Other identity | 11.67* | 1.3 | 2.31 | 1.07 | 2.58 | 0.84 | 1.67 | 0.71 |
| (1.46–93.50) | (0.33–5.18) | (0.69–7.81) | (0.30–3.86) | (0.72–9.22) | (0.23–3.03) | (0.44–6.37) | (0.20–2.55) | |
| I don’t know | 2.92 | Omitted | 2.25 | Omitted | 1.62 | 1.47 | 0.67 | 1.24 |
| (0.87–9.72) | (0.73–6.91) | (0.51–5.12) | (0.28–7.60) | (0.20–2.28) | (0.24–6.38) | |||
Discussion
Novel findings from this research include furthering our understanding of how several sexual identities are related to child maltreatment types, depression, anxiety, at-risk alcohol use, and at-risk cannabis use among a community sample of emerging adults. Findings indicate that compared to identifying as heterosexual, sexual identity of homosexual, gay, or lesbian; bisexual; and other identity were associated with an increased likelihood of having a child maltreatment history, along with an increased likelihood of many poor mental health and substance use outcomes. Notably, more significant models were found for depression and anxiety and fewer for at-risk cannabis and at-risk alcohol. When looking at the analysis stratified by those with and without a child maltreatment history, different trends were noted, suggesting that the association between sexual identity and poor mental health and substance use outcomes may be worsened in some cases when sexual minority individuals also experience child maltreatment. Findings from the current study affirm previous studies that indicate that individuals who identify as other than heterosexual are at an increased likelihood of experiencing childhood violence (Andersen & Blosnich, 2013; Austin et al., 2016, 2022; Charak et al., 2019; Clements-Nolle et al., 2018; Friedman et al., 2011; Jiang et al., 2023; Schnarrs et al., 2019; Tran et al., 2022). Our findings advance this work with further detailed analyses that include several sexual identities and several child maltreatment types.
From a human rights perspective, children and youth have the right to live free from all forms of violence (Whalen, 2022). Policies are needed to protect children when it is noted that some children and youth may have a greater likelihood of violence exposure. Promoting and maintaining safe environments for all children is essential to ensure healthy development and to reduce mental disorders and at-risk substance use. This may be especially necessary for children and youth who identify with a sexual identity other than heterosexual. From a societal perspective, it is important to invest in public education and resources that normalize and promote acceptance of all sexual identities and remove any tolerance for violence against children and youth. Parenting programs that educate caregivers about children’s development, including sexual and gender identity, orientation, and expression, may prevent and reduce childhood violence. It is also important for clinicians to be aware of the relationships between sexual identity, child maltreatment, depression, anxiety, and at-risk substance use when an individual accesses care in an effort to improve mental health as individuals move from adolescence into adulthood.
Limitations
Findings from the current study should be interpreted while considering the limitations of the research. First, although the sample was similar to the general population of Manitoba based on sex and household income at the first baseline data collection (Statistics Canada, 2017), because the data collection methods were non-random and due to attrition since baseline, we cannot refer to this as a representative sample. Second, only one geographical area in Canada was included in the study. Third, it is possible that sexual minorities may underreport identities, resulting in some misclassification. Fourth, we did not have adequate power to examine gender identity. This would be important to investigate in future work of emerging adults. Finally, future work with a larger sample size should include moderation analyses to confirm whether a child maltreatment history significantly modifies or worsens the relationship between sexual identity and depression, anxiety, at-risk alcohol use, and at-risk cannabis use.
Conclusion
Although there are notable limitations with this work, the current study does advance our understanding of sexual identities, child maltreatment, mental health, and substance use using a community sample of emerging adults in Canada. It also highlights the need to further invest in this area so that this work can be examined at the national level with larger nationally representative samples so that all models can be adequately executed. Specifically, recommendations have been put forward for national surveys in Canada to include all child maltreatment types, to ask about experiences in younger children, including younger than 15 years, and to collect longitudinal data (Gonzalez et al., 2021). The findings from the current study further highlight the need for nationally representative data to inform policy and practice and to promote health and well-being at a critical point in development for children, youth, and emerging adults.
Ensuring safe, stable, and nurturing relationships and environments is needed to prevent child maltreatment (Centers for Disease Control & Prevention, 2014). The current research indicates that sexual identity is associated with an increased likelihood of experiencing child maltreatment, depression, anxiety, at-risk alcohol use, and at-risk cannabis use among emerging adults in a community sample. When sexual minority individuals also experience child maltreatment, trends in the data indicate that mental health and substance use outcomes may worsen. More work is needed to confirm these findings using a large nationally representative sample of youth and emerging adults from across Canada. Health and social service professionals working with children and families should be aware of the relationship between sexual identity and poor mental health and substance use outcomes, and how having a child maltreatment history may worsen these associations. It is important that clinicians working with children and families are using evidence-based methods to recognize and safely respond to child maltreatment (Gonzalez et al., 2021; Kimber et al., 2021; Mathews et al., 2022). Preventing violence, improving mental health, and reducing at-risk substance use among sexual minority youth remain public health priorities.
Contributions to knowledge
What does this study add to the existing knowledge?
- Novel findings are that compared to identifying as heterosexual, sexual identity of homosexual, gay, or lesbian; bisexual; and other identity were associated with an increased likelihood of child maltreatment history, along with an increased likelihood of many poor mental health and substance use outcomes.
- Notably, more significant models were found for depression and anxiety and fewer for at-risk cannabis and at-risk alcohol use among this sample of emerging adults.
- Trends suggest that the association between sexual identity and poor mental health and substance use outcomes may be worsened in some cases if the individual also has a child maltreatment history.
What are the key implications for public health intervention, practice, or policy?
- Promoting and maintaining safe environments for all children is essential to ensure healthy development and to reduce mental disorders and at-risk substance use. This may be especially necessary for children and youth who identify with a sexual identity other than heterosexual, to reduce the occurrence of mental disorders and substance use as they enter adulthood.
- From a societal perspective, it is important to invest in public education and resources that normalize and promote acceptance of all sexual identities and remove any tolerance for violence against children and youth.
Acknowledgements
The authors thank the parents and adolescents who participated in the Well-Being and Experiences Study and took the time to share their experiences for this work.
Funding
Afifi is supported by a Tier I Canada Research Chair in Childhood Adversity and Resilience. This work was supported by a Canadian Institutes of Health Research (CIHR) Operating Grant: Data Analysis Using Existing Databases and Cohorts (IHDCYH).
Availability of data and material
Due to ethics agreements, these data are not allowed to be shared.
Code availability
N/A.
Declarations
Ethics approval
Health Research Ethics Board at the University of Manitoba.
Consent to participate
Informed consent was obtained from participants.
Consent for publication
N/A.
Conflict of interest
The authors declare no competing interests.
Footnotes
Footnote Group
References
Untitled section
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Associated Data
Data Availability Statement
Due to ethics agreements, these data are not allowed to be shared.
N/A.