Sexual Victimization Outcomes and Adjustment Among Bisexual Women: A Review of the Quantitative Literature

Bisexual Identity and Sexual Victimization

Bisexual women report higher rates of sexual victimization compared to their heterosexual and lesbian counterparts. Findings from the 2010 National Intimate Partner and Sexual Violence Survey (Walters et al., 2013) indicate that bisexual women experience significantly higher rates of lifetime rape (46.1%) compared to both lesbian (13.1%) and heterosexual women (17.4%). The lifetime prevalence of sexual violence other than rape (including sexual coercion, unwanted sexual contact, and non-contact unwanted sexual experiences) was also higher among bisexual women (74.9%) than lesbian (46.4%) and heterosexual women (43.3%). The majority of bisexual women who have experienced rape (and sexual victimization other than rape) report that perpetrators were male (Walters et al., 2013). Rates of sexual revictimization, or sexual victimization during more than one developmental period (e.g., both child sexual abuse [CSA] and adult sexual victimization), are also higher among bisexual women (Hughes et al., 2010b), which indicates that bisexual women may have greater exposure to violence across the lifespan. Bisexual women’s experiences of sexual victimization may also be more severe compared to heterosexual and lesbian women, as bisexual women are more likely to report completed rape (Hequembourg et al., 2013; Walters et al., 2013). Compared to heterosexual women, a greater proportion of bisexual women experience symptoms of PTSD related to partner violence including rape (Walters et al., 2013). In a nationally representative sample of adults in the United States (U.S.), Evans-Polce et al. (2020) found that past-year prevalence of PTSD was highest among bisexual women (21%) compared to heterosexual women (5.7%), lesbian/gay women (7.4%), heterosexual men (3%), gay men (6.2%), and bisexual men (10.3%). Further, bisexual women also appear to experience worse mental health outcomes than heterosexual and lesbian women in anxiety and depression (Ross et al., 2018), hazardous alcohol use (Hughes et al., 2014), and suicidality (Salway et al., 2019).

Elevated rates of sexual victimization may contribute to mental health disparities among bisexual women given the robust association between sexual victimization and psychopathology. Bisexual women may experience more repeated victimization, more types of victimization, and a greater severity of victimization, leading to greater and more complex trauma exposure and, likely, increased mental health burden. Thus, it is imperative to understand post-victimization outcomes and factors involved in adjustment among bisexual women. The minority stress framework (Meyer, 2003) considers identity-based stigma and minority stress as leading factors in sexual minority health disparities and can help contextualize the adjustment process.

Minority Stress Framework

Meyer’s (2003) minority stress theory posits that minority individuals experience chronic stressors due to the stigmatization of their identities that add burden to the individual and lead to negative health outcomes. Minority stressors are conceptualized on a continuum of distal (i.e., external events) to proximal (internal to the individual): (a) experiences of enacted stigma, such as discrimination and hate crime victimization, (b) expectations of stigma and rejection, visibility management processes (e.g., outness, identity concealment), and (c) internalized stigma (i.e., internalization of negative societal attitudes and stereotypes about one’s sexual identity). The framework recognizes how “characteristics of the minority identity,” such as how important the identity is for one’s sense of self (i.e., identity centrality) or how negatively or positively (i.e., identity affirmation) one views the minority identity, may relate to health outcomes directly and via interactions with other minority stressors. Further, Meyer (2003) explicitly identifies experiences of violence as a distal minority stressor. Bisexual women’s experiences of sexual victimization can be conceptualized as a distal stressor leading to negative mental health outcomes. There is evidence minority stress theory also can help explain why bisexual women may be at risk for sexual victimization in the first place and may similarly contribute to our understanding of the process of adjustment following victimization (Flanders et al., 2019; Murchison et al., 2017; Salim et al., 2020).

Antibisexual Stigma and Sexual Victimization

The term “binegativity” describes the stigmatization of bisexuality within heterosexual and lesbian/gay communities (Dyar et al., 2014). Bisexual people experience stigma, prejudice, and discrimination stemming from not only heterosexist reactions against non-heterosexual sexual expression, but also from monosexism (i.e., beliefs that attraction to multiple genders is illegitimate or inferior; Roberts et al., 2015). In a national U.S. sample, Dodge et al. (2016) found negative stereotypes and attitudes toward bisexual people were common. These negative stereotypes of bisexuality can be organized into two broad categories: illegitimacy/instability stereotypes and sexual irresponsibility stereotypes. The first category includes perceptions of bisexual people as confused about their sexual identity, as being truly heterosexual or lesbian/gay, or as in the process of transitioning to a monosexual identity. The second category includes perceptions of bisexual people as sexually irresponsible and of bisexual women as promiscuous and hypersexual (Dodge et al., 2016; Flanders et al., 2016). Further, binegativity is dual-sourced in that bisexual people experience stigma from heterosexual as well as lesbian and gay individuals (Brewster & Moradi, 2010).

Experiences of antibisexual stigma may lead to expectations of binegativity and rejection due to one’s bisexual identity and to internalized binegativity (Paul et al., 2014). Internalization of stereotypes about the illegitimacy/instability of bisexuality may contribute to sexual identity uncertainty, a minority stress process that appears particularly salient for bisexual people (Dyar & London, 2018). Experiences of stigma depend on the degree to which individuals disclose their bisexual identity to others (Roberts et al., 2015), thus individuals may choose not to disclose (or conceal) their identity as a way to manage stigma. However, paradoxically, identity concealment may be related to increased psychological distress (Dyar & London, 2018; Feinstein et al., 2020).

Bisexual women’s greater risk for sexual victimization may, in part, be due to experiences of bisexual minority stress. Bisexual women report experiences of sexual harassment and unwanted sexual advances when they disclosed their identity and report perceptions of being targeted for sexual victimization as a result of binegativity (Flanders et al., 2017, 2020; Van et al., 2019). Indeed, Flanders et al. (2019) reported antibisexual stigma was linked to sexual victimization among individuals with plurisexual identities (plurisexual is an umbrella term encompassing sexual identities with attractions to multiple genders such as bisexual, pansexual, and queer). Specifically, experiences of antibisexual stigma from heterosexual as well as lesbian/gay people were associated with increased risk of sexual victimization among participants who identified as bisexual, bisexual plus another plurisexual identity, and as plurisexual identity other than bisexual. Antibisexual stigma was also associated with increased risk of sexual coercion. In addition, Flanders et al. (2020) found that internalized binegativity was related to both rape and sexual coercion among bisexual people. Similarly, Salim et al. (2020) found experiences of antibisexual stigma and sexual coercion risk among bisexual women can be explained in part by internalized sexual minority stigma. Sexual identity disclosure was examined as a moderator, but the authors found that this link was significant regardless of bisexual women’s degree of outness (Salim et al., 2020). Sexual minority stress may also confer risk for sexual victimization via other non-group specific factors, such as emotion dysregulation and substance misuse (Fitzpatrick et al., 2020). Thus, bisexual minority stress may be directly and indirectly associated with increased risk of sexual victimization for bisexual women.

The minority stress framework may also be helpful to contextualize post-victimization adjustment among bisexual women, given that violence researchers have called for more ecologically informed models on mental health sequelae (Neville & Heppner, 1999). As noted by Campbell et al. (2009): “Sexual assault does not occur in social and cultural isolation: we live in a rape-prone culture that propagates messages that victims are to blame for the assault, that they caused it and indeed deserve it” (p. 226). To reach a comprehensive understanding of sexual victimization among bisexual women, researchers must take into account the impact of antibisexual stigma, and how that stigma interacts with other factors at various levels of the social ecology. Given the specific vulnerabilities and minority stressors that bisexual women may face, it is imperative for research to examine outcomes of sexual victimization among this group. The purpose of the current review of quantitative studies is to synthesize what is known to date about the correlates of sexual victimization among bisexual women, and to identify gaps in the literature to determine directions for future research.

Study Characteristics

Sample sizes within the 15 studies ranged from N = 107 to 34,653, with representation of bisexual women ranging from N = 8 to 1925 and from 0.5% and 100% of the total samples. It was unclear how sexual orientation was assessed in Andres-Hyman et al. (2004), whereas all other studies used participant self-identification as bisexual. All studies were conducted in the U.S. and most were cross-sectional, with the exceptions of Rhew et al. (2017) and Sigurvinsdottir & Ullman (2016a, 2016b). Four studies recruited women with histories of sexual victimization and used convenience sampling by advertising in the general community, in university/college campuses, and in agencies catering to the community in general and to victims specifically (Long et al., 2007; Sigurvinsdottir & Ullman, 2015, 2016a, 2016b), whereas one study included victims in outpatient therapy (Andres-Hyman et al., 2004). Three studies used national samples and random sampling (Blosnich & Horn, 2011; Drabble et al., 2013; Hughes et al., 2010a). One study (Hughes et al., 2010b) combined a national sample of women with a sample of lesbian women from the greater Chicago area. The remaining studies recruited convenience samples of sexual minority or bisexual women.

Studies used different age cutoffs for distinguishing childhood versus adult sexual victimization. For example, CSA was defined as victimization that occurred before the age of 14 (Sigurvinsdottir & Ullman, 2015), 17 (Andres-Hyman et al., 2004), or 18 (Hughes et al., 2010a). For the purposes of the current review, we discuss findings in relation to experiences occurring before the age of 18 as CSA and experiences after the age of 18 as adult victimization. For studies that operationalized adult victimization at ages after 14, we discuss results in terms of adolescent/adult victimization given that we are unable to determine if the experience happened in the adolescent years between 14 and 18 or afterward. Two studies assessed recent victimization in the past 30 days (Kelley et al., 2018a, 2018b) or in the past 12 months (Blosnich & Horn, 2011), which we considered adult sexual victimization.

Sexual Victimization and Substance Use Outcomes

Sexual Victimization and Psychological Distress

Theoretical Implications

Campbell et al. (2009) proposed an ecological model describing the effect of sexual assault on women’s mental health and reviewed the literature on sexual assault sequelae, drawing on Bronfenbrenner’s (1977, 1986) ecological theory of human development. In this model, Campbell identified factors involved in recovery across the social ecology (i.e., individual, micro, meso/exo, macro, and chronosystem levels). With this framework at the forefront, the current literature review examined bisexual women’s adjustment following sexual victimization to synthesize results from quantitative studies in this area. Most notably, all but six of the studies focused solely on individual-level variables using bisexual identity as a predictor of outcomes of victimization or explored mediators/moderators at the individual level. Two of these also explored the intersection of bisexual identity and race at the individual level (Sigurvinsdottir & Ullman, 2015, 2016b). Beyond the individual level, four studies examined factors at the micro and meso/exosystem levels (i.e., reactions to assault disclosure, social support), and two studies examined revictimization, which we conceptualized as a chronosystem factor. Only three studies measured bisexual minority stress, and it is notable that only one formally tested the interaction of sexual victimization and binegativity (McConnell & Messman-Moore, 2019). The dearth of research on the role of minority stress in bisexual women’s sexual assault outcomes is a significant gap in the literature that precludes a comprehensive understanding of post-assault adjustment. Bisexual minority stress is related both to sexual victimization (Flanders et al., 2019; Salim et al., 2020) and to mental health and substance use outcomes (Dyar & London, 2018; Dyar et al., 2014; Molina et al., 2015). Disparities among bisexual women and the role of bisexual minority stress have been documented in the literatures on mental health, substance use, and sexual victimization. Yet, these literatures have largely remained separate lines of inquiry and rarely include integrated models that examine variables related to both trauma and bisexual minority stress. It is imperative to examine how bisexual minority stress fits into the post-assault adjustment process.

In Figure 2 we provide a conceptual model, adapted from Campbell et al.’s (2009) ecological model, which we hope can inform future research with bisexual women. Sexual minority stressors may directly fit within levels of the ecological model and interact with general factors already identified in the literature (e.g., reactions to assault disclosure and coping motives) to predict outcomes. We expect bisexual identity and minority stress to be impactful across all levels of the social ecology, not simply as a characteristic at the individual level. We theorize that the most proximal minority stressors, as identified within the minority stress framework (e.g., internalized binegativity, Meyer [2003]), and characteristics of the minority identity (e.g., identity centrality and identity uncertainty) may be most relevant at the individual, assault, and microsystem levels. For example, Salim et al. (2021) found that internalized binegativity moderated the relation of negative reactions to sexual assault disclosure and hazardous drinking. Less proximal stressors (e.g., expectations of binegativity/rejection, visibility management strategies [outness and identity concealment]), which are not solely individual factors but have an interpersonal context, may be most relevant at the assault, micro, and meso/exosystem levels. For example, the degree to which women disclose their bisexual identity may influence their experiences with binegativity (Roberts et al., 2015), although one study suggested that outness does not change the relation of antibisexual stigma and sexual victimization (Salim et al., 2020). Thus, more research is needed to examine visibility management strategies in relation to sexual victimization and adjustment. Bisexual identity milestones and shifts in societal attitudes toward bisexuality may be important chronosystem level factors to consider; for example, there may be generational differences in bisexual individuals’ adjustment following sexual assault. We expect distal stressors such as binegativity and negative bisexual stereotypes to operate across all levels of the ecology creating the broader sociocultural context of adjustment and recovery for bisexual victims. To illustrate, results from McConnell and Messman-Moore (2019) indicated that experienced binegativity moderated the link between CSA and hazardous drinking. Binegativity can be experienced at the micro or meso/exosystem levels in interpersonal contexts, but antibisexual stigma in the broader society can also be conceptualized at the macrosystem level of analysis.

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Figure 2.

Proposed conceptual model of sexual violence recovery among bisexual women. Note. Adapted from Campbell et al. (2009).

Clinical and Research Implications

The limited available research on PTSD and depression suggests that bisexual women with histories of sexual victimization experience significant difficulties in psychological adjustment. Social support and social reactions to sexual assault disclosure may be particularly relevant for bisexual women’s outcomes. Negative attitudes toward bisexual individuals are prevalent in society (Dodge et al., 2016) and discrimination can occur within both heterosexual and lesbian/gay communities (Brewster & Moradi, 2010). This may limit bisexual women’s ability to find positive social support after an assault (Hsieh, 2014). Bisexual women may benefit from mental health services sensitive to their specific needs (Barker, 2015). Increasing bisexual women’s social network and access to supportive others may also aid in post-assault adjustment.

It is imperative that professionals working with bisexual women provide culturally sensitive counseling, especially given that bisexual clients may experience binegativity from mental health professionals (Eady et al., 2011). Clinicians must be knowledgeable about binegativity and issues related to bisexuality, as well as positive aspects of holding a bisexual identity in order to deliver affirmative care (Barker & Langdridge, 2008; Rostosky et al., 2010). Antibisexual stigma from mental health providers appears to negatively impact help-seeking intentions of bisexual adults (DeLucia & Smith, 2021). Notably, Ovrebo et al. (2018) found that trauma-exposed bisexual women were less likely to seek mental health services than lesbian women were and less likely to disclose their sexual identity to providers. Thus, providers should not make assumptions about clients’ sexual orientation (e.g., based on partner gender) and practice affirmative care with all clients. The use gender-inclusive language when discussing dating and relationship experiences (i.e., partner vs. boyfriend/girlfriend) may be one way to avoid perpetuating bisexual invisibility and invalidation. Health providers may consider adding information and resources specific to bisexuality in their offices and waiting rooms, as well as displaying different signs to signal safety to bisexual clients (e.g., bisexual pride symbol; Feinstein et al., 2019). Feinstein et al. (2019) have outlined a multi-level approach, ranging from individual intervention with bisexual clients to advocacy and support for public policy promoting equal rights, necessary for addressing mental health and substance use disparities.

The greater prevalence and severity of victimization among bisexual women may be one explanation for substance use disparities documented in the literature. Bisexual women may use alcohol and other substances as a way to cope with distress following sexual victimization. However, given that alcohol and substance use increase the risk for sexual victimization (Kelley et al., 2018a), this coping strategy may actually place bisexual women at risk for repeated victimization. Thus, it may be important to target substance use behaviors directly in therapy and to identify alternative coping mechanisms to help bisexual women manage post-trauma distress more effectively. Clinicians should be aware of the high rates of sexual victimization and revictimization among their female bisexual clients and consider working on strategies to reduce future risk in addition to addressing substance use. Binegativity and internalized stigma are linked to victimization risk (Flanders et al., 2019; Kelley et al., 2018a; Salim et al., 2020); thus, targeting internalized binegativity and helping bisexual women access more bi-affirmative environments may be worthwhile efforts. Further, policies aimed at reducing binegativity on a societal level are needed to shift attitudes toward bisexual people in order to improve mental and sexual health outcomes. Finally, it is evident that any interventions targeting the high rates of substance use among bisexual women must take into account the role of lifetime sexual victimization and adopt a trauma- and minority stress-informed approach.

Research Limitations and Future Directions

A notable limitation of the body of quantitative literature reviewed is the significant dearth of literature on bisexual women’s experiences and a particular gap in studies focused on mental health outcomes. The existing literature focuses only on PTSD and depression symptoms, and extant research has significant methodological drawbacks. All study participants had histories of sexual victimization, which allowed for assessment of PTSD in relation to the sexual trauma, but did not permit a direct test of the link between victimization and depression. Further, findings are limited in terms of generalizability and replicability given that three of the five studies included women from the same parent project (baseline sample in Sigurvinsdottir and Ullman [2015] and subsample in Sigurvinsdottir and Ullman [2016a, 2016b]), and one study had only eight bisexual women represented in the study (Andres-Hyman et al., 2004). The lack of research in this area is somewhat surprising given bisexual women report worse outcomes than their lesbian and heterosexual counterparts across a range of mental health concerns, including depression, anxiety, and suicidality (Bostwick et al., 2010; Salway et al., 2019), which are all increased among sexual assault victims (Dworkin et al., 2017). Thus, more research is needed to elucidate how experiences of sexual victimization relate to mental health concerns among bisexual women, while taking into account bisexual minority stress. We have proposed a framework for integrating bisexual minority stress in research that we hope can inform future studies on victimization and post-assault adjustment. However, it is important to note that the current review included only studies that reported results of quantitative research. Qualitative methodologies are particularly suited for research on sexual minority mental health (Flanders et al., 2017; Ross et al., 2010), can provide a more in-depth understanding of the individual’s experience, and may identify novel variables and research questions to test in larger, quantitative studies. Our review does not include findings from qualitative studies, which is a significant limitation, and future research would benefit from a synthesis of knowledge from qualitative research.

The extant literature on sexual victimization outcomes among bisexual women has focused largely on substance use behaviors. This is an important line of inquiry because substance use rates are elevated among bisexual women, are detrimental to health and wellbeing, and may increase risk for sexual revictimization. Yet, the primary focus on substance use can be problematic as it may further add to the stigmatization (or even pathologizing) of bisexual women and community. Further, two studies (Kelley et al., 2018a, 2018b) had inclusion criteria for participants to report past 30-day binge drinking, which may have resulted in a high risk sample not representative of bisexual women in general. Scholars have highlighted the need for research on positive resilience and health-promoting factors among sexual minorities (Meyer, 2015). Researchers should be cognizant of how we frame research questions and report results, and aim to examine positive identity and factors promoting resilience following sexual victimization. Further, while we found high rates of sexual victimization among bisexual women, the current review focused only on distress-related outcomes, which may have led to a selection of articles with greater rates of reported victimization. Future research may conduct a broad review of the literature and examine rates of victimization in research more generally versus research focused on distress.

Another significant limitation of the literature is the predominant use of retrospective, cross-sectional designs. This limits our interpretation of the directionality of the reported results, especially considering that outcomes of sexual victimization (e.g., psychological distress and alcohol use) can also be risk factors for victimization (Ullman et al., 2009). Thus, it is likely that there are bidirectional effects that can only be parsed apart in longitudinal studies. Given that bisexual women are vulnerable to experience repeated victimization, it may be especially important to track prospectively the dynamics between these experiences and related outcomes.

Consideration of Intersectional Identities¹

The diversity of sexual identity is notably lacking in the current literature. Although we used a broad search strategy for plurisexual identities (an umbrella term which refers to individuals with attractions to more than one gender) by including search terms such as “pansexual” and “queer,” studies meeting inclusion criteria were conducted with women who identified as bisexual. One exception, the study by Hughes et al. (2010b), also reported separate results for mostly heterosexual and mostly lesbian identified women. Therefore, the summary of research in the current review reflects the experiences of women who identify as bisexual but may not capture the experiences of other plurisexual women given the heterogeneity in the experiences of different plurisexual groups (Mitchell et al., 2015). Importantly, there is evidence that risk for sexual victimization may be even more elevated among individuals who identify with a plurisexual identity other than bisexual (Flanders et al., 2019).

In this review, our focus was on victimization in relation to sexual minority stress in particular. Thus, studies regarding the experiences of transgender women and gender diverse people were not included. Most studies included in the current review did not provide information about participants’ gender identity. However, we might presume that samples were comprised of mostly cisgender bisexual women, thus the current review likely reflects experiences of cisgender women. We recognize this is an assumption based in cisnormativity, and it is imperative that future research assess and report the gender identity of their participants to gain a more accurate picture of whose experiences are being captured in research. The experience of bisexual minority stress differs between cisgender and gender diverse people, and transgender and gender diverse bisexual adults experience worse mental and physical health outcomes (Taylor et al., 2020) than cisgender bisexual people.

Risk for sexual victimization may be more elevated among gender diverse bisexual individuals compared to cisgender bisexual women (Anderson et al., 2021), indicating that people with intersecting bisexual and gender minority identities may be particularly vulnerable. Intersectionality theory, originating from Black feminist scholarship (Collins, 1991; Crenshaw, 1989, 1991), examines how individuals’ multiple co-occurring social identities, such as sexual orientation, gender, race, socioeconomic status, and nationality, are not independent but intersecting in mutually influencing ways to shape one’s experience and social inequalities. The importance of considering intersectionality to understand health disparities for groups holding multiple marginalized identities has been highlighted (Bowleg, 2012). With the exception of a few studies that included racially diverse samples of women (e.g., Long et al., 2007), the majority of samples were predominantly White. Further, only two studies included an analysis on the intersection of Black racial identity and bisexual identity related to outcomes of victimization (Sigurvinsdottir & Ullman, 2015, 2016b). Thus, there is a significant gap in research concerning race. The proposed conceptual model reflects the experiences of White (presumably) cisgender bisexual women but does not fully capture the intersectionality of women’s bisexual identity with racial and ethnic identities, or the complex interactions among sexual minority stress, racial minority stress, and sexual victimization. Only one study examined other demographic characteristics in their analysis (Drabble et al., 2013). The remaining studies either controlled for demographic characteristics or did not disaggregate the effects of demographic variables for sexual orientation groups, which fails to consider the intersectional experiences of women holding multiple socially disadvantaged identities. Examination of other aspects of diversity (national origin and ability status) is also lacking. Future research on victimization, recovery, and bisexual mental health must continue to include underrepresented and marginalized survivors (Bryant-Davis, 2019; Dworkin et al., 2019; Ghabrial & Ross, 2018).