The social determinants of health (SDoH) framework, which builds upon Bronfenbrenner’s ecological systems theory (1992), has become increasingly prominent in behavioral health research (13–15). This framework emphasizes that health outcomes are shaped not only by biological and genetic factors but also by social and environmental influences. As such, the SDoH framework offers a nuanced understanding of the social contexts that contribute to health behaviors and disparities.

SDoH refers to the structural and systemic conditions that shape health and well-being, including economic stability, access to healthcare, housing security, and neighborhood environments (16). The WHO Commission on the social determinants of health defines SDoH as “the conditions in which people are born, grow, live, work, and age.” These conditions are shaped by families, communities, and the distribution of money, power, and resources at global, national, and local levels, as well as by policy decisions at each of these levels (17). SDoH significantly influences an individual’s ability to meet basic needs such as food security, medical care, and safe living conditions, ultimately shaping health outcomes and contributing to disparities in both physical and mental well-being (18, 19).

Increasingly, research has highlighted the role of SDoH in adolescent well-being (20). Adolescence is a pivotal stage of development marked by biological and neurological changes that influence how young people interact with their families, peers, schools, and health-related behaviors. These shifts significantly shape their future health and life trajectories. Research consistently shows that broader societal structures, such as a country’s economic status, the distribution of wealth, and access to education – all have a profound impact on adolescent well-being. At the same time, nurturing relationships at home, in school, and among peers are essential in supporting adolescents’ growth and facilitating their adjustment into adulthood.

Cumulative deficits in SDoH have been consistently linked to an elevated risk of mental health disorders, substance use, and suicidality (21–26). These social stressors create chronic adversity, which can erode coping mechanisms, reduce resilience, and increase vulnerability to maladaptive behaviors.

The relationship between SDoH and suicide or substance use is complex and multifaceted. Financial hardship can exacerbate psychological distress, restrict access to mental health care, and contribute to a pervasive sense of hopelessness. Limited healthcare availability delays early intervention for mental health issues, increasing the likelihood of individuals self-medicating with substances. Unstable or unsafe living conditions—including exposure to violence, neglect, or high-risk environments—further intensify stress and emotional dysregulation, making individuals more vulnerable to both substance use and suicidal ideation.

Despite growing recognition of the role of SDoH in shaping health outcomes, research has often examined these factors in isolation rather than in interaction with childhood trauma—particularly experiences of CSA and IBSA. Emerging evidence underscores that the risk for CSA and IBSA is shaped by a convergence of individual, relational, and contextual factors. A meta-analysis focused exclusively on CSA identified prior sexual victimization, familial instability (e.g., presence of a stepfather), and parental dysfunction (e.g., intimate partner violence, mental illness) as the strongest predictors of CSA risk (27). These findings emphasize the ecological and cumulative nature of sexual victimization, particularly in environments marked by compromised caregiving and structural disadvantage. Similarly, Paradiso et al. (28) found that gender-based power imbalances, prior sexual abuse, digital vulnerability, and limited social support significantly increase the risk for IBSA, especially among girls and LGBTQ+ youth. Together, these studies suggest that sexual abuse, whether in childhood or digital contexts, often emerges from conditions of systemic inequity and vulnerability and that these experiences may interact in cyclical, compounding ways. For example, CSA survivors may struggle with trust, emotional regulation, and self-worth—difficulties that, when combined with economic hardship or limited social support, may further intensify mental health challenges. However, the directionality of these relationships remains unresolved, underscoring the need for research that examines the interplay of SDoH and childhood trauma to better inform prevention and intervention strategies.

A more integrative framework is needed to examine how the intersection of CSA, IBSA, and cumulative SDoH deficits shapes long-term mental health trajectories. Adolescents facing both sexual abuse and structural disadvantages may experience compounded risks for severe behavioral health outcomes, including suicide and overdose (8, 9, 11). The accumulation of structural disadvantages likely amplifies the psychological consequences of CSA and IBSA, deepening vulnerabilities and worsening outcomes (29). However, empirical research on these cumulative and interactive effects remains scarce, limiting the ability of healthcare providers, policymakers, and intervention programs to implement comprehensive, evidence-based strategies. This study aims to bridge these gaps by analyzing data from a large, diverse sample of young adults to explore how different forms of child sexual abuse—hands-on CSA, IBSA, and their co-occurrence—interact with cumulative SDoH deficits in predicting suicide attempts and overdose risk during adolescence and young adulthood.

CSA and IBSA have both been identified as significant risk factors for adverse mental health and behavioral indicators, including suicidality and substance use disorders (4, 8). While substantial research has examined the long-term effects of hands-on CSA, comparatively less attention has been given to IBSA, despite its overlap with CSA (6) and growing prevalence in digital spaces (3, 12). IBSA introduces unique challenges for survivors, as the permanence and widespread dissemination of explicit images can lead to persistent victimization, ongoing distress, and social isolation (1). Additionally, SDoH—structural and environmental conditions such as economic stability, healthcare access, and housing security—may play a crucial role in shaping adolescent and young adult mental health outcomes (17, 20). Previous studies have demonstrated that individuals facing multiple SDoH deficits are at heightened risk for depression (30), suicidality (22), and substance use (21). However, research has primarily treated SDoH as an independent predictor of adverse health outcomes rather than examining how it interacts with childhood trauma, particularly CSA and IBSA. Understanding the intersection of these factors is essential for identifying the most vulnerable populations and informing targeted interventions.

This study seeks to fill these critical gaps by exploring how cumulative SDoH deficits and different forms of child sexual abuse (hands-on CSA, IBSA, or both) jointly are associated with risk of suicide attempts and drug overdose prior to age 18 and during their lifetime. Using data from a large, diverse sample of young adults (ages 18–28; n = 2,630), we construct a cumulative SDoH deficit scale encompassing five domains: economic stability, social and community context, housing stability, healthcare access, and neighborhood environment. We also categorize abuse experiences into four groups: no abuse, hands-on CSA only, IBSA only, and both hands-on CSA and IBSA. Specifically, we hypothesize that: (1) Higher SDoH deficits will be associated with increased risk of suicide attempts and overdose, independent of CSA or IBSA history; (2) Experiencing both hands-on CSA and IBSA will be associated with the highest risk of suicide attempts and overdose compared to either form of abuse alone; (3) The combination of multiple SDoH deficits and CSA/IBSA will have a compounding effect on suicide and overdose risk, with the highest predicted probabilities observed among those experiencing both abuse types and four or more SDoH deficits. In a more exploratory manner, we examine how different SDoH domains contribute uniquely to risk.

Data were collected for the Digital Life Study through an online questionnaire designed to oversample sexual and gender minority (SGM) individuals. We recruited individuals aged 18–28 across the U.S. through advertisements on Facebook and Instagram. If a prospective participant clicked on the “Learn more” button on the advertisements, they were linked to a secure screener survey hosted by Qualtrics survey platform. Eligibility included being age 18–28, living in the U.S., having English proficiency, and endorsing potential IBSA screening items (explained below). Those who were deemed eligible in the screener survey were redirected to the main behavioral survey, also in Qualtrics.

Our sample was not designed to be nationally representative, as the goals of the larger study were to maximize the number of participants who had experienced IBSA prior to age 18. However, our sample was diverse in terms of urbanicity (26.6% small town or rural area, 38.8% suburban area next to a city, 28.6% urban or city area). To maximize the number of participants with IBSA experience prior to age 18, we used two items in the screener survey: “On a scale of 1 to 5, how likely would you be to…” (1) “Send a photo or video that was sexual?” and (2) “Have someone ask you for a photo or video that was sexual?” Initially, those who answered a likelihood of “2” to above on either of the screener questions were directed to the full survey. Responses were presented to participants on a sliding scale of 1 (Not at all likely) to 5 (Extremely likely) (values labels were not provided for “2,” “3” or “4”). This criterion was modified throughout recruitment to maximize the number of participants with IBSA involvement (i.e., increasing the criteria to answering “3” or above to either of the screener items). Most participants (80%) in the analytic sample were recruited under the “2” + threshold, while only 20% were enrolled after increasing the threshold to “3” or higher.

The analytic sample includes n = 2,630 participants who had survey data on key measures that were added to the survey about half-way through recruitment (including SDoH items before age 18, suicide attempt prior to age 18, and overdose prior to age 18). The larger study included n = 6,204 participants who completed the survey between June 28, 2023 and April 1, 2024. In the data cleaning process for the larger study, cases were dropped due to reasons such as declined consent (n = 227), duplicate or suspected fraud (n = 289), incomplete response (n = 1729), or had no matching screener data (n = 161). To screen out any suspect or extreme responses, a research assistant on our team checked open-ended qualitative incident narratives provided by the respondent (“In a few sentences, please describe what happened.”). Any that were deemed as “suspect” were flagged and reviewed. Cases were considered complete if they reached the 90% Progress threshold determined by Qualtrics survey platform. There were 20,795 completed screener surveys, yielding 6,204 full valid surveys, indicating a completion rate of 30%. The survey took about 25 min to complete. Once complete, participants were entitled to a $15 Amazon gift card, mailed to valid U.S. non-P. O. box mailing addresses, as a thank you for their time. All participants provided consent for their participation. The study was reviewed and approved by the University of New Hampshire Institutional Review Board

Data were analyzed using Stata/SE version 17.0. Data were weighted to general population targets from the Current Population Survey for 18–28 year olds on age, gender, education, race and Hispanic ethnicity, as well as gender and sexual identity from Pew Research Center (37, 38).¹ Weights were applied in bivariate and multivariate analyses. Missing data were less than 5% and conservatively coded as “no” for dichotomous variables.

First, to examine differences in SDoH deficits by abuse type, we use bivariate analyses to report the endorsement of each SDoH deficit, as well as total deficit count, among those reporting each type of abuse. Overall Chi-squared test statistics were reported. We also examined pairwise comparisons (i.e., differences in endorsement of SDoH domains between each level of abuse – CSA vs. none, IBSA vs. none, both vs. none).

Next, we analyzed the endorsement of our outcome variables, any or before 18 suicide attempt and any or before 18 overdose, for SDoH deficit count and abuse type with overall Chi-squared tests. Pairwise comparisons were again used to compare endorsement of each outcome by each level of SDoH deficit (i.e., 1 vs. 0, 2 vs. 0, 3 vs. 0) and abuse type (i.e., CSA vs. none, IBSA vs. none, both vs. none).

Using logistic regressions, we calculated the predictive margins of each outcome based on the intersection of the number of SDoH deficits and abuse type. We repeat these analyses at the intersection of SDoH domain and abuse type. All models controlled for current age, sexual minority identity before age 18, gender minority identity before age 18, racial minority identity, ethnic minority identity, and sex at birth. Statistical significance threshold was set at p < 0.05.

Nearly 40% of participants reported experiencing only IBSA before age 18 (38.3%), 12.4% experienced both CSA and IBSA, and 3.7% experienced CSA only. About half (45.7%) did not report any abuse. Given our method of oversampling for IBSA victimization, it is not surprising that rates of IBSA are higher than nationally representative samples (5). Rates of lifetime and before age 18 suicide attempt were higher than national estimates (29.6 and 25.0% respectively), though national estimates, such as that from the Youth Risk Behavioral Survey, often use different timeframes for attempt history (i.e., past 12 months vs. lifetime) (39, 40). Approximately 8.8% of our sample reported lifetime drug overdose, and 5.1% reported overdosing on drugs before age 18 (Table 1). Overdose rates were also higher than national estimates, though estimates typically rely on emergency department data rather than self-report and may not be comparable (41).

Our findings reinforce prior research indicating that CSA is significantly associated with adverse health indicators, including suicide attempts and substance use disorders (9, 11, 42). However, this study extends the literature by showing that IBSA is similarly associated with these indicators, with relationships comparable to those observed in hands-on CSA. While IBSA can occur independently, the overlap observed in this study highlights how youth subjected to hands-on CSA are also at heightened risk for IBSA. This pattern underscores the need to conceptualize IBSA as part of a broader continuum of sexual exploitation rather than treating it as an isolated phenomenon. The presence of both abuse types was associated with the highest percentage of suicide attempt before age 18, and, although not statistically significant at the multivariate level, was noticeably larger (41.7% both those experiencing both IBSA and CSA vs. 25.5% with CSA only); this was likely due to a lack of statistical power given the small number of participants with a suicide attempt prior to age 18 that reported only hands-on CSA (n = 32). Although more research is needed, findings offer some early indication that cumulative victimization may amplify psychological distress and increase vulnerability to self-harm when occurring contemporaneously (that is, during childhood). These findings align with poly-victimization theory (43, 44) which posits that exposure to multiple forms of abuse exacerbates mental health risks by reinforcing learned helplessness, increasing emotional dysregulation, and diminishing protective coping mechanisms. This also supports the adverse childhood experiences literature which highlights the particularly damaging health impact of experiencing multiple adversities in childhood (45, 46).

The findings emphasize the importance of extending the field’s conceptualization of IBSA, CSA and mental health to include the contribution of SDoH. Rather than focusing exclusively on demographic variables in understanding these relationships, this study examines potentially modifiable social and structural variables that have been connected to health outcomes. Indeed, data from this study underscores the importance of taking into account SDoH when addressing and screening for suicide and overdose outcomes in both adolescence and young adulthood. The high percentages of negative health indicators among participants reporting both CSA and IBSA may be a product of simultaneously experiencing higher SDoH deficits. Indeed, higher SDoH deficits were independently associated with increased suicide and overdose risk, even in the absence of abuse history. Specifically, youth with four or more SDoH deficits had significantly higher predicted probabilities of suicide attempts and overdoses compared to those with fewer or no deficits. These results suggest that structural disadvantages can amplify the psychological impact of CSA and IBSA, further increasing the likelihood of adverse health outcomes.

The accumulation of SDoH across multiple sectors, including economic instability, discrimination, housing insecurity, and limited healthcare access appears to compound psychological distress, further exacerbating risk among youth who have also experienced sexual victimization. These findings extend our knowledge by highlighting the compounding impact of experiencing different childhood sexual abuse and exploitation experiences while also experiencing different levels of SDoH deficits. Indeed, although young adults with histories of sexual abuse were more likely to have poorer mental and behavioral health indicators, both before and after age 18, this was particularly true for those same youth who also experienced increasing numbers of SDoH deficits. These results are consistent with growing research in the field about links between discrimination and health (47) and suicide behaviors in particular (48), demonstrating that structural disadvantages contribute to poor mental health by limiting access to protective resources, increasing exposure to chronic stressors, and reinforcing cycles of social marginalization. Overall, those with both IBSA and hands-on CSA were the most likely to report each type of SDoH as well as more overall. This supports prior research that highlights the relationship between risk factors across multiple levels of social ecology and child health (49).

This study revealed several key findings that have implications for both abuse intervention and mental and behavioral health prevention programs. First, IBSA is linked with CSA in important ways that could help CSA investigations. Although the current data cannot differentiate between IBSA that was specifically part of CSA or whether it was a separate incident, it does suggest the high likelihood of youth experiencing CSA to also having experienced IBSA. CSA investigations conducted by multi-disciplinary teams and law enforcement should always consider the existence of IBSA as it not only has implications for victim impact, but also could serve as concrete evidence in cases rather than relying on victim testimony.

Second, suicide and overdose screening efforts must incorporate both SDoH and abuse histories. Our findings indicate that relying solely on SDoH screenings without considering CSA or IBSA could miss at-risk youth. Likewise, screening solely for abuse history without assessing social determinants may overlook the compounded vulnerabilities that arise from structural disadvantages. As noted by Karatekin et al. (50) in a scoping review on Adverse Childhood Experiences, research often focuses on the “downstream” factors of victimization and adversity rather than the structural, modifiable “upstream” factors and interventions occurring outside of the home. Given the demonstrated cumulative effect of SDoH deficits, intervention strategies must address these broader systemic issues rather than focusing exclusively on individual risk factors.

Third, survivors of IBSA may require specialized interventions that account for the ongoing fear of image circulation, public exposure, and social stigmatization reported by some survivors. Findings from the current analyses suggest the combination of both CSA and IBSA may compound health indicators for some youth. This, combined with research documenting the unique mental health impact of IBSA, even in the context of CSA (7), suggests IBSA victimization may extend beyond the initial event for some youth, with long-term consequences that can shape identity, self-esteem, and mental health. Future research should examine how IBSA-specific interventions can mitigate these enduring harms.

Future research needs to better understand when and how IBSA is part of a specific CSA victimization, and how this impacts mental health. Indeed, survivors of IBSA often report feeling ongoing fear over the circulation or resurfacing of their images online, as well as worry about being recognized in public. The sharing of images and the public accessibility of the images is one of the most difficult aspects of the crime to overcome (51, 52), and contributes to the feelings of ongoing vulnerability, helplessness and powerlessness (52–54).

There is also a need for longitudinal research which explores the long-term implications of IBSA, particularly in comparison to hands-on CSA. Prior research has established long-term negative outcomes linked with CSA (10, 55), but little is known about how IBSA interacts with these effects over time. Understanding the interplay between these abuse types and SDoH can inform more comprehensive prevention and intervention efforts. Additionally, qualitative research is needed to capture the nuanced experiences of IBSA survivors. Future studies should examine how survivors navigate ongoing digital threats, social stigma, and emotional distress related to their victimization. Exploring these lived experiences can help tailor interventions to better support those affected by IBSA and CSA. Finally, more research is needed to better understand the range of IBSA experiences that occur which do not involve hands-on CSA. These incidents were commonly reported in this sample. The diversity of these cases likely require different approaches to prevention and intervention.

All of the constructs in this study were measured retrospectively and focused on experiences prior to the age of 18. As such, causal relationships cannot be determined. Sampling bias could exist due to the opt-in recruitment methods via social media, although this was less of a concern given ads did not reveal study aims. Moreover, it is possible that our screening method did not capture those with past IBSA experiences who may have different mental health profiles than those who enrolled in the study. That is, it is possible that some with IBSA victimization would answer the screener questions with “1” (not at all likely), given they are now more wary of sharing sexual photos or videos of themselves because of their victimization experience. These individuals may look different, with respect to health indicators, than eligible study participants. This is an important consideration for future research aiming to measure IBSA and related experiences. The key variables, including hands-on CSA, drug overdose, and IBSA could be part of the same episode; we were unable to separate these out as unique experiences due to the structure of the survey. Moreover, our measurement of hands-on CSA only included adult perpetrators. It is possible that some of those coded into the “No abuse” category did, in fact, experience sexual abuse by a sibling or peer. This was beyond the scope of this study, and additional research should examine these episodes in the context of abuse experiences and mental health indicators.

Fraud is always a concern with social media recruitment (56), however, we included extensive procedures to deter and detect any fraudulent entries; steps designed and tested by the authors across multiple studies which reduces concerns in this regard (7). A further limitation is that we were unable to separately examine adulthood (after age 18) health indicators from overall lifetime measures due to the low endorsement rates of after age 18 only suicide attempts and overdoses in our sample. This means that while we could assess suicide attempts and overdoses that occurred before age 18, our lifetime measures include both adolescent and adult experiences, preventing a clear understanding of how CSA, IBSA, and SDoH deficits uniquely affect health beyond adolescence. Finally, our measures of suicide attempt did not capture important details, like age of onset, frequency and duration, that would be helpful for practitioners in assessing risk level.