Arch Sex Behav (2014) 43:107–117 DOI 10.1007/s10508-013-0224-8

SPECIAL SECTION: SEXUAL HEALTH IN GAY AND BISEXUAL MALE COUPLES

Adult Attachment Among Partnered Gay Men: Patterns and Associations with Sexual Relationship Quality Tyrel J. Starks • Jeffrey T. Parsons

Published online: 3 December 2013  Springer Science+Business Media New York 2013

Abstract Previous research has found secure adult attachment to be associated positively with dimensions of main partner relationship quality and negatively with sexual risk taking and sex with casual partners among heterosexuals in primary relationships. Potential associations between adult attachment and aspects of relationship functioning have received limited attention among gay men. Data were collected from both members of 344 gay male couples as part of a community survey (Mage = 38.6, SD = 9.4). Participants completed a shortened version of the Adult Attachment Inventory (Collins & Read, 1990) and the Dyadic Sexual Communication Scale (Catania, 1998). They reported the frequency of sex with main partners and the number of casual male unprotected sex partners. Data were analyzed using the Actor-Partner Interdependence Model. Securely attached individuals reported the highest levels of sexual communication and men with securely attached partners were the most likely to report having sex with

T. J. Starks
J. T. Parsons Center for HIV/AIDS Educational Studies and Training (CHEST), New York, NY, USA T. J. Starks Department of Psychology, Pace University, New York, NY, USA J. T. Parsons (&) Department of Psychology, Hunter College of the City University of New York (CUNY), 695 Park Ave, New York, NY 10065, USA e-mail: [email protected] J. T. Parsons CUNY School of Public Health at Hunter College of CUNY, New York, NY, USA J. T. Parsons Health Psychology and Basic and Applied Social Psychology Doctoral Programs, The Graduate Center of CUNY, New York, NY, USA

their partners as least once per week. Avoidantly attached men reported significantly more casual unprotected anal intercourse (UAI) partners compared to other attachment styles. Having an avoidantly attached partner was alsoassociated with an increase in the number of UAI partners reported. Attachment style is relevant to the sexual relationship quality and sexual safety of partnered gay men. Cognitive-interpersonal intervention approaches developed to target attachment-related cognitions and behaviors may be relevant to HIV prevention efforts in this population. Keywords Same-sex couples
Substance use
Sexual risk
Gay men
Sexual orientation

Introduction More than 30 years into the epidemic, men who have sex with men (MSM) continue to account for the majority of new HIV infections each year (CDC, 2012). Recent years have seen increased incorporation of relationship factors into prevention research as accumulating findings have indicated that main partners are a major source of new infections (Davidovich, de Wit, & Stroebe, 2004; Goodreau et al., 2012; Sullivan, Salazar, Buchbinder, & Sanchez, 2009). Sullivan et al. estimated that as many as 68 % of new HIV infections among MSM in the U.S. were contracted from main partners. While Goodreau et al. (2012) suggested that the number may be somewhat more modest (32–39 %), they echoed assertions that main partnerships are an important vector of transmission and that approaches to HIV prevention appropriate for MSM in stable relationships are lacking and warrant development. Sullivan et al. (2009) attributed the increased risk of main partner HIV infection to a higher number of sex acts, a higher number of receptive anal sex acts (which are most likely to

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result in transmission), and a lower likelihood of condom use between main partners. Consistent with these hypotheses, Mustanski, Newcomb, and Clerkin (2011) studied predictors of main partner transmission risk among young men who have sex with men. In addition to older partner age, and longer relationship length, they found that perceiving the relationship as‘‘serious,’’was associated with HIV transmission risk. Thus, the finding that unprotected anal intercourse (UAI) was more likely to occur in relationships perceived as ‘‘serious,’’ highlighted the potential importance of perceived emotional connection in understanding HIV transmission risk within relationships. Attachment theory may provide auseful organizational framework in which to examine such emotional ties in close relationships (Hazen & Shaver, 1994). Attachment theory describes the affectional bonds—attachments—formed between people (Hazen & Shaver, 1987). Beginning with early interactions with caregiversinchildhood, humansform internal working models— cognitive representations—of themselves (as worthy/unworthy of care from others) and others (as reliable vs. unreliable) (Bowlby, 1969, 1977). These working models continue to shape (and be shaped by) interactions in close relationships across the lifespan(Ainsworth,1985; Hazen&Shaver,1987,1994).Attachment theory conceptualizes sexual/romantic relationships—pair bonding—as a function of three interrelated behavioral systems: attachment, caregiving, and sex (Ainsworth, 1985; Hazen & Shaver, 1987). The attachment system represents the collection of behaviors whose function is to maintain proximity to an attachment figure. The degree of proximity necessary to prevent anxiety, and the behavioral repertoire utilized to maintain this proximity, are shaped by early interactions with caregivers. Once established, these patterns of behavior continue to function into adulthood, governing interactions in other intimate relationships (Hazen & Shaver, 1994). The literature varies in the number of prototypical styles of adult attachment identified. Three styles are identified with relative consistency across studies: secure, anxious-ambivalent, and anxious-avoidant, (Collins & Read, 1990; Hazen & Shaver, 1987, 1994; Mickelson, Kessler, & Shaver, 1997). These styles of attachment are characterized by different working models of self and others (Hazen & Shaver, 1994). Secure attachment is characterized by positive models of self and others. Anxiousambivalent individuals have negative working models of self, but more positive working models of others (coupled with preoccupation that others will abandon them or be unavailable) (Bartholomew & Horowitz, 1991; Hazen & Shaver, 1994). Anxious-avoidant individuals have positive working models of self, but negative working models of others. Four-group models have been offered which distinguish between dismissing and fearful styles of avoidant attachment, the former being characterized by a positive evaluation of self and the latter being characterized by a negative evaluation of self (Bartholomew & Horowitz, 1991; Griffin & Bartholomew, 1994).

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Attachment theory has been criticized for underestimating the importance of infant characteristics in development, over-estimatingthestabilityofinternalworkingmodelsovertime,andoveremphasizing categorical differences that mask individual variability within attachment groups. Studies of infant temperament suggest that characteristics of infants themselves exert an effect on attachment-relatedparent–childinteractions(Calkins&Fox,1992; Seifer, Schiller, Sameroff, Resnick, & Riordan, 1996). Developmental research has indicated a moderate degree of attachment stability from childhood into adulthood, with later attachmentrelevant interactions within significant relationships also exerting some effect on current attachment style (Fraley, 2002; Waters, Weinfield, & Hamilton, 2000). Some researchers have favored studying attachment in terms of working model dimensions that underlie categorical attachment styles as an alternative to attachment classification (e.g., Ciesla, Roberts, & Hewitt, 2004; Hankin, Kassel, & Abela, 2005; Ramirez & Brown, 2010). Despiteitslimitations,existingresearchinheterosexual populations has demonstrated the relevance of adult attachment to general relationship quality and sex-specific aspects of relationship quality, including the frequency of sexual behavior between primary relationship partners. These associations with general and sexual aspects of relationship quality occur alongside associations with sexual behavior with partners outside of the relationship (and related attitudes) and sexual risk taking behavior. Secure attachment has been positively associated with indicators of relationship quality and satisfaction among dating (Collins & Read, 1990) and married couples (Butzer & Campbell, 2008; Mehta, Cowan, & Cowan, 2009). In addition, insecure attachment styles have been associated with decreased sexual frequency (Brassard, Shaver, & Lussier, 2007) and decreased sexual satisfaction among married couples (Butzer & Campbell, 2008). Avoidant attachment has been associated with a more positive evaluation of casual sex (Brennan & Shaver, 1995; Feeney, Noller, & Patty, 1993). Characteristics of insecure attachment have been associated with a range of sexual risk behaviors, including: a greater likelihood of having sex without a condom, negative attitudes towards condoms, decreased assertiveness regarding condom use, and increased use of substances in conjunction with sex (Bogaert & Sadava, 2002; Feeney, Kelly, Gallois, Peterson, & Terry, 1999; Feeney, Peterson, Gallois, & Terry, 2000). Attachment theory may be particularly relevant to the study of the sexual health of men in same-sex relationships because of unique challenges faced by gay and bisexual men during their social-sexual development. Gay and bisexual children and adolescents face potential parent and peer rejection due to their sexual orientations or other forms of gender non-conformity (Landolt, Bartholomew, Saffrey, Oram, & Perlman, 2004; Ryan, Huebner, Diaz, & Sanchez, 2009). They may face challenges in identifying potential relationship partners and enacting romantic relationships that their heterosexual peers do not (Diamond, Savin-Williams, & Dube, 1999). Finally, they may experience sexual orientation-related

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stigma within the context of society in general (Herek, 2004; Steffens, 2005). All of these potentially negative social exchanges may increase the likelihood of forming and maintaining insecure types of adult attachment. Formulations of internalized homophobia (Meyer & Dean, 1998; Shidlo, 1994), minority stress (Meyer, 1995), and rejection sensitivity (Pachankis, Goldfried, & Ramrattan, 2008) commonly applied in studies of the mental health of gay and bisexual men, all bear some resemblance to attachmenttheory’sconceptsofworkingmodelsofselfandothers. While several studies have found that attachment security is positively associated with indicators of social and psychological health among MSM (Gwadz, Clatts, Leonard, & Goldsamt, 2004; Landolt et al., 2004; Riggs, Vosvick, & Stallings, 2007; Sherry, 2007), data directly examining the associations among adult attachment, sexual behavior, and sexual relationship quality among MSM are sparse. Available data suggest that partnered gay men and lesbian women do not differ generally from their heterosexual counterparts in their average levels of attachment security (Roissman, Clausell, Holland, Fortuna, & Elieff, 2008) and attachment style was found to be unrelated to open versus monogamousagreementsbetweenpartneredgaymen(Ramirez& Brown, 2010). Ciesla et al. (2004) found that negative representations of self (a key feature of the ambivalent attachment style) wereassociatedwithsexualrisktakingamongHIVpositiveMSM. The Current Study The existing literature suggests that attachment theory may be relevant as a mechanism for understanding sexual relationships and sexual health decisions; however, there is a paucity ofresearch examining associations among attachment style, sexual risk taking,andsexualrelationshipqualityamongpartneredgaymen.The goal of the current study was to examine attachment patterns in a community sample of partnered gay men and evaluate the significance of associations between attachment style and (1) unprotected anal intercourse (UAI) with casual partners and (2) dimensions of main partner sexual relationship quality (sexual communication and sexual frequency). Based upon findings from heterosexual samples, we hypothesized that (1) avoidant attachment would be positively associated with UAI with casual partners, (2) avoidant attachment in either partner would be negatively associated with perceived sexual frequency with main partners, and (3) avoidant and ambivalent attachment in either partner will be associated with decreased sexual communication scores.

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N = 172 matched couples). Partnered men who were not classified into dyads were either not attending the event with their partner, or their partner did not consent to participate. Procedure The Sex and Love Study, version 3.0 utilized an adapted crosssectional, street-intercept method (Miller, Wilder, Stillman, & Becker, 1997) to gather data from gay and bisexual men at a series of two day-long gay, lesbian, and bisexual (GLB) community events in New York City and Los Angeles (Grov, Parsons, & Bimbi, 2010; Kelly, Bimbi, Nanı´n, Izienicki, & Parsons, 2009; Nanı´n, Bimbi, Grov, & Parsons, 2009). This approach to collecting data has been used in numerous studies (Carey, Braaten, Jaworski, Durant, & Forsyth, 1999; Chen, Kodagoda, Lawrence, & Kerndt, 2002; Kalichman & Simbaya, 2004; Rotheram-Borus et al., 2001), including those focused on GLB persons (Benotsch, Kalichman, & Cage, 2002; Kalichman et al., 2001) and has been shown to provide data that are comparable to those obtained from other more methodologically rigorous approaches (Parsons & Halkitis, 2002), such as time–space sampling. The research team hosted a booth at each community event. A research team member actively approached each person who passed the booth. Information about the project was given to all potential participants followed by an invitation to participate. The survey response rate was high (87.0 %). During the consent procedure, project staff asked participants if they were in a relationship. If the participant indicated that he was, the project staff asked if his partner was present at the event. If the participant’s partner was in attendance and agreed to participate, the dyad’s surveys were assigned a unique code that linked them in the data set. Participants were provided with a clipboard and paper copy of the questionnaire, which took approximately 15–20 min to complete. Participation was anonymous, no identifying information was collected from participants, and all participants personally deposited their own completed questionnaire into a secure box at the booth. When responding to the survey, participants were advised to complete the questionnaire away from others (including theirpartners)toensureanonymity.Participantsreceivedavoucher forfreeadmissiontoamovieasanincentivetocompletethesurvey. Survey data were entered into an SPSS database and checked/ verifiedbyprojectstaffforaccuracy.Allprocedureswerereviewed and approved by the Hunter College Institutional Review Board.

Method

Measures

Participants

Demographics

A total of 1,781 men responded to a street-intercept survey, 730 (41.0 %) identified having a‘‘primary’’partner. Of these, we were able to classify 344 into members of a dyad (47.1 %;

Participants indicated their age, sexual identity, race and ethnicity, HIV serostatus (positive, negative, unknown), education level, income level and relationship length.

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Adult Attachment Scale Attachment style was assessed using a shortened (15-item) version of the Adult Attachment Scale (AAS) (Collins & Read, 1990). The scale assesses three dimensions of attachment (5 items per scale): Close—level of comfort with emotional closeness (e.g.,‘‘I find it relatively easy to get close to others.’’), Depend—level of comfort depending on others (e.g., ‘‘I am comfortable depending on others.’’) and Anxiety—fears about being rejected by others (e.g.,‘‘I often worry my partner will not want to stay with me.’’). Participants indicated their agreement with each item on a 4-point Likert scale (1 = Strongly Disagree, 4 = Strongly Agree). Note that the Likert-type scale used here was shortened compared to the traditional AAS, which utilizes a 5-point response scale. Items were coded so that higher scores indicated higher levels of each dimension. Close, Depend, and Anxiety subscales had internal consistencies (Cronbach’s a) of .64, .61, and .66, respectively. This level of reliability was similar to that observed in the original measure (.75, .72, and .69) (Collins & Read, 1990) and, more recently, by Ciesla et al. (2004) (a = .61, .75, and .72) and Ramirez and Brown (2010) (a = .71, .77, and .67). Only attachment anxiety subscale scores were significantly dependent within couple. The level of dependence observed in all AAS dimensions was below the threshold for consequential dependence upon one another (ICCclose = .05; ICCdepend = .05; ICCanxiety = .23, p\.01).

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rates of agreement for reported sexual behavior observed by Starks, Gamarel, and Johnson (2013) and Carballo-Dieguez, Remien, Dolezal, and Wagner (1999) in HIV serodiscordant couples. Sexual Risk Participants reported the number of casual partners with whom they had engaged in UAI in the previous 3 months. The number of casual UAI sex partners reported by dyad members were significantly, but not consequentially, dependent upon one another (ICC = .19; p\.01). Analysis Plan We conducted analyses in two phases. In the first phase, we conducted preliminary analyses of dependence in couple members’ responses. Subsequently, we identified attachment subtypes using latent class analysis (LCA) of AAS subscale scores in a manner analogous to the original construct development work conducted by Collins and Read (1990). In the second phase, we compared attachment styles on variables including demographic characteristics, number of casual UAI partners, sexual communicationwithmainpartners,andfrequencyofsexual activitywith main partners. Phase 1

Sexual Communication Participants’ levels of communication about sexual issues were measured using a shortened (11-item) version of the Dyadic Sexual Communication (DSC) Scale (Catania, 1998). Items included,‘‘Talking about sex is a satisfying experience for both of us’’and‘‘Some sexual matters are too upsetting to discuss with my partner.’’Participants indicated their agreement on a 4-point Likert-type scale (1 = Strongly Disagree, 4 = Strongly Agree). Items were coded such that higher scores indicated better communication (a = .73). Reports of sexual communication by dyad members were statistically, but not consequentially, dependent upon one another (ICC = .40; p\.01). Weekly Sexual Activity with Primary Partners Participants provided information about the frequency of sexual behavior with their primary partner using a series of ordinal responses (‘‘not at all,’’‘‘less than once per month,’’‘‘once per month,’’‘‘two to three times per month,’’‘‘once a week,’’‘‘two to three times per week,’’ and ‘‘daily’’). Ordinal responses were dichotomized into‘‘once a week or more’’vs.‘‘less than once per week.’’ Reports of sexual frequency by dyad members were statistically and consequentially dependent upon one another (j = .60; p\.01). In 81 % of couples, partners agreed that they had sex more or less than once per week. This rate is similar to the

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The relatedness of dyad members’ responses to demographic questionsandAASsubscale scoreswasevaluated using theintraclass correlation (ICC) (for continuous variables) and Cohen’s j (for categorical variables). When applied to data from dyads, both statistics may assume values between -1 and 1. A value of zero implies that two members of the same couple are no more similar to one another than two members of different couples. As the absolute value increases, it implies that couple members’ responses are increasingly related to one another. An ICC or a j of 1.0 indicates that members of the same couple responded identically and all individual variability is explained by couple membership (Kenny, Kashy, & Cook, 2006). Consistent with the recommendations of Kenny and Judd (1986), observations were treated as independent when ICC or j values were\.45. Latent class models from one to three classes were estimated, and the fit of each model was compared using the MPlus program version 6.1 (Muthe`n & Muthe`n, 2006). LCA tests whether a latent variable, specified as mutually exclusive classes, accounts for observed co-variation among manifest, categorical variables (Ramirez & Brown, 2010). By following steps outlined by others (Grov, Starks, Rendina, & Parsons, 2012; Ramo, Grov, Delucchi, Kelly, & Parsons, 2010), model fit was evaluated using three sets of criteria: (1) The Lo-Mendel-Ruben adjusted Likelihood Ratio (LMR LR) (Lo, Mendell, & Rubin, 2001) provides a test of whether a model with k categories represents a statistically

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significant improvement in fit over a model with k - 1 categories by comparing the log-likelihood values associated with the respective models. A statistically significant LMR indicates improvement in fit associated with the additional category. (2) The Bayesian information criterion (BIC) (Raferty, 1995) and Akaike’s information criterion (AIC) (Akaike, 1973) quantify information lost by imposing a model on the observed data. Low BIC or AIC values indicate a better model fit (Muthe`n & Muthe`n, 2000). (3) Finally, the entropy value measures the clarity of the classification. Entropy values range from 0 to 1, with 0 indicating random assignment to category and 1 representing perfect classification. Entropy values closer to 1.0 are preferred, though no formal threshold for‘‘good’’fit has been established (Muthe`n & Muthe`n, 2000; Ramaswamy, DeSarbo, Reibstein, & Robinson, 1993). For the present study, we fit a series of latent class models to AAS subscale data and evaluated the best fitting model using the criteria outlined above (LMR LR, AIC, BIC, and entropy). In the context of these indicators, we considered class size and theoretical significance when making final model selections. Classes with extremely small n’s are of limited utility, while classes that have important theoretical implications or predictive value may be considered in the presence of ambivalent indicators of fit. Based on the patterns of AAS scale elevations in each class, meaningful labels or definitions of the latent classes can be made. Phase 2 In our second series of analyses, we utilized the actor-partner interdependencemodel(APIM)framework(Kennyetal.,2006)to evaluate associations between attachment style and a series of outcomes associated with sexual relationship quality, including: number of casual UAI partners, sexual communication with main partners, and frequency of sexual activity with main partners. The APIM is a multi-level model. It distinguishes between Level 1 (or individual level) variables (on which partners within a dyad may differ, such as age) and Level 2 (couple-level) variables (where both members of a dyad share the same value, such as relationship length). At Level 1, two kinds of effects are calculated within the APIM. The actor effect represents the relationship between a participant’s score on a criterion variable and the participant’s own score on a predictor variable; the partner effect represents the relationship between a participant’s score on a criterion variable and his partner’s score on a predictor variable. Separate models were calculated for each outcome. All models controlled for the race, age, income, and HIV status of each partner (at Level 1) as well as the length of the couple’s relationship (at Level 2).

Results Demographic information for the sample is shown in Table 1. Average age of participants in the sample was 38.57 years

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(SD = 9.39).ThesamplewasprimarilyWhite(60.5 %),themajority had completed at least a 4-year college degree (63.3 %), and earned more than $40,000 annually (70.8 %). Couples had been together for an average of 72.61 months (SD = 72.93). Measures of dependence suggested that the degree of relatedness in partners’ scores on AAS subscales was not above the threshold for consequential dependence (Kenny & Judd, 1986), suggesting AAS data did not violate assumptions of independence which underlie LCA. Latent Class Analysis of Adult Attachment Patterns Model Selection Examination of ICC values for partners’ responses suggested that AAS subscale scores did not meaningfully violate the assumptions of independence that underlie LCA. Model fit statistics for one to three class solutions are shown in Table 2. All indicators supported the conclusion that a two-class model was superior to a model with one class. While the LMR LR was non-significant for the three-class model, all other indicators of fit improved with the introduction of a third class. Examination of attachment subscale elevations suggested the third category corresponded to the anxious-avoidant attachment style as identified by Collins and Read (1990). Across the three classes, patterns of significant differences among attachment subscale scores were highly similar to those observed with the original scale (Collins & Read, 1990). We concluded that a three-class solution fit the data best from both theoretical and statistical standpoints. Latent Class Response Patterns and Definitions Between-class differences in attachment subscale scores are shown in Table 1. Individuals in Class 1 had the highest scores on subscales assessing comfort with depending on others and comfort with closeness, and the lowest scores on the anxiety subscale. This pattern of scale elevations was consistent with the secure attachment style identified by Collins and Read (1990). This group was labeled secure. Individuals in Class 2 had significantly lower scores on comfort with closeness and comfort depending on others and significantly higher scores on the anxiety subscale compared to individuals in the secure attachment class. This pattern of scale elevations was consistent with the Anxious Ambivalent attachment style identified by Collins and Read (1990). This group was labeled ambivalent. Individuals in Class 3 had scores on comfort with closeness and comfort with dependence that were significantly lower than both the Secure and Anxious Ambivalent classes. Their anxiety subscale scores were significantly higher compared with men in the secure class; however, they did not differ significantly from those in the Anxious-Ambivalent class. This pattern of scale elevations was consistent with the Anxious Avoidant attachment

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Table 1 Demographic characteristics Overall N (%)

j

344 (100)

Race

Class 1: secure

Class 2: ambivalent

Class 3: avoidant

116 (33.7)

199 (57.8)

29 (8.0) v2(6) = 6.88

.17*

White

208 (60.5)

63 (59.5)

121 (60.8)

African American

23 (6.7)

10 (8.6)

12 (6.0)

1 (3.4)

Latino

69 (20.1)

17 (14.7)

46 (23.1)

6 (20.7)

Other

44 (12.8)

20 (17.2)

20 (10.1

4 (13.8)

HIV-status

18 (62.1)

v2(2)\1.0

.36**

Positive Negative/unknown Education

42 (12.2)

15 (13.0)

23 (11.6)

4 (14.3)

296 (86.0)

100 (87.0)

172 (88.2)

24 (85.7) v2(2) = 2.49

.18*

4 year degree or more

217 (63.3)

80 (69.0)

120 (60.6)

17 (58.6)

\4 year degree

126 (36.7)

36 (31.0)

78 (39.4)

12 (58.6)

Annual income

v2(2) = 1.64

.22**

\$40,000

99 (29.2)

85 (73.9)

137 (70.3)

18 (62.1)

C$40,000

240 (70.8)

30 (26.1)

58 (29.7)

11 (37.9)

Adult attachment scales Comfort depending upon others Comfort with closeness Attachment anxiety

Test statistic

M (SD)

ICC

M (SD)

M (SD)

13.10 (2.97)

.05

15.48 (2.49)a

12.26 (2.16)b

9.36 (2.48)c

F(3, 341) = 112.84**

14.88 (3.06)

.05

17.86 (1.66)a

13.94 (1.96)b

9.40 (1.36)c

F(3, 341) = 314.23**

a

b

b

9.92 (3.07)

.23**

7.50 (2.03)

11.19 (2.63)

M (SD)

10.93 (3.53)

F(3, 341) = 79.55**

* p\.05, ** p\.01 Table 2 Goodness of fit for latent class models AIC

adj BIC

LMR-LR

p

Entropy

1 class

5,225.48

5,229.49

NA

2 class

5,096.68

5,103.37

131.18

\.001

0.64

3 class

5,085.16

5,094.52

18.72

ns

0.67

NA

AIC Akaike Information Criteria, adj BIC sample size adjusted Bayesian Information Criteria, LMR-LR Lo-Mendell-Ruben Adjusted Likelihood Ratio test

style identified by Collins and Read (1990). This group was labeled avoidant. Adult Attachment and Sexual Communication APIM model results for attachment variables are shown in Table 3. There were significant actor effects associated with anxious avoidant and anxious ambivalent attachment. Men in the anxious avoidant class had significantly lower sexual communication scores compared with men in the securely attached class, as did men in the anxious ambivalent class. Changing ref erent categories revealed that anxious avoidant men had significantly lower sexual communication scores than anxiousambivalent men as well (B = -3.61, 95 %CI -5.53, -1.69; b = -.20; p\.01). There was a significant partner effect of anxious avoidant attachment. Men with anxious avoidant partners had sig-

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nificantly lower sexual communication scores than those with securely attached partners. Men whose partners were anxious ambivalent did not differ significantly from those with anxious avoidant or securely attached partners. No actor or partner effects were observed for race, age, HIV status, income, or relationship length.

Odds of Weekly Sexual Activity Between Main Partners APIM model results are shown in Table 3. All actor effects were non-significant. Men’s attachment style was not associated with their own odds of reporting having had sex at least weekly with their partners. There were significant partner effects for anxious ambivalent and anxious avoidant attachment. Men whose partners were in either of these classes had significantly lower odds of reporting having had sex at least weekly with these partners than men with securely attached partners. Changing referent categories revealed that men whose partners were categorized as anxious avoidant did not differ significantly from those whose partners were categorized as anxious ambivalent (B = -0.43, 95 %CI -1.24, 0.38; expB = 0.65, p = .30). With respect to covariates, reports of sexual frequency were not associated with the age, race, income, or HIV status of either partner. Longer relationship duration was negatively associated with sexual frequency (B = -0.01, 95 %CI -0.01, -0.001; p\.05).

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Table 3 APIMs of sexual relationship quality measures regressed on attachment style Sexual communication B

95 % CI

35.13**

(32.72, 37.55)

Actor

-6.60**

(-8.71, -4.49)

Partner

-2.11*

Intercept

Weekly sexual activity with main partners b

b

expB

Number of casual UAI partners B

95 % CI

-4.02**

(-5.85, -2.19)

b

B

95 % CI

expB

-1.05*

(-2.07, -0.03)

-.37

-0.29

(-1.12, 0.53)

-.04

0.75

3.45**

(2.05, 4.84)

.54

(-4.07, -0.15)

-.12

-1.02*

(-1.86, -0.19)

-.15

0.36

1.53**

(0.48, 2.57)

.24

Avoidanta 31.5 4.62

Ambivalenta Actor

-2.99**

(-4.37, -1.61)

-.30

-0.23

(-0.77, 0.31)

-.06

0.79

0.25

(-1.17, 1.67)

.07

1.28

Partner

-0.69

(-2.05, 0.68)

-.07

-0.59*

(-1.15, -0.04)

-.16

0.55

-0.10

(-1.49, 1.29)

-.03

0.90

Note Regression type varied by outcome: Sexual communication = Ordinary Least Squares; Weekly Sexual Activity with main Partners = Logistic; and Number of Casual UAI Partners = Poisson a

Referent category is Secure attachment

* p\.05, ** p\.01

Number of Casual Unprotected Anal Sex Partners Because the number of UAI casual partners is a count variable, APIM models were calculated specifying a Poisson distribution with an exchangeable correlation. Results are shown in Table 3. There was a significant actor effect of anxious avoidant attachment. Men with this attachment style reported significantly more casual UAI partners than those categorized as securely attached. In addition, changing referent categories revealed that anxious avoidant men reported significantly more casual UAI partners than anxious ambivalent men as well (B = 3.20, 95 % CI 1.63, 4.76; expB = 24.5; p\.01). There was also a significant partner effect of anxious avoidant attachment. Men with avoidantly attached partners reported significantly more casual UAI partners than those with securely attached partners. Changing referent categories revealed that men with anxious avoidant partners also reported more casual UAI partners than men with anxious ambivalent partners (B = 1.63, 95 %CI 0.00, 3.26; expB = 5.10; p = .05). With respect to covariates, HIV positive men reported significantly more casual UAI partners than HIV negative men (B = 2.03, 95 %CI 1.22, 2.83; expB = 7.61; p\.01), as did men whose partnerswereHIV positive (B = 1.37,95 %CI0.70, 2.03; expB = 3.94; p\.01). There was also a significant partner effect of age. Men with younger partners reported fewer casual UAI partners (B = -0.15, 95 %CI -0.24, -0.05; expB = .86; p\.01). A participant’s own age was not significantly associated with the number of UAI casual partners. Actor and partner effects of income were not associated with the number of casual UAI partners. At Level 2, relationship length was positively correlated with number of casual UAI partners (B = 0.01, 95 %CI .003, 0.02; expB = 1.01; p\.01). Two additional factors are relevant to the understanding of this model. First, the size of the regression coefficients must be viewed in light of the small intercept. For example, while the size of the association between avoidant attachment and

the outcome is large (avoidantly attached men had 31.5 times the number of casual UAI partners compared to their securely attached counterparts), the average number of casual UAI partners among securely attached participants was small after accounting for covariates included in the model (Bintercept = -4.02) (see Table 3). Second, a negative binomial model was estimated to test for the presence of over-dispersion in the outcome. The resulting dispersion parameter was non-significant (B = 3.38; 95 %CI -5.37, 12.13, p = .45) and supported the specification of a Poisson distribution.

Discussion Results from the current study suggest that adult attachment style is relevant to the sexual lives of partnered gay men. Secure attachment was associated with higher levels of sexual relationship quality. Securely attached individuals reported the highest levels of sexual communication and men with securely attached partners were the most likely to report having sex with their partners as least once per week. These findings were consistent with observations in heterosexual samples in which avoidant attachment was associated with avoidance of sexual activity, and husbands’ ambivalent attachment was associated with wives’ avoidance of sexual activity (Brassard et al., 2007). Feeney et al. (1999) also found evidence of impaired communication about sexual safety among insecurely attached heterosexual individuals. These findings underscore the importance of partner attachment style to evaluations of sexual relationship quality. Men whose partners were avoidant reported lower sexual communication scores than those whose partners were ambivalent or secure. This is consistent with theoretical conceptualizations and empirical observation of diminished trust and self-disclosure among avoidantly attached individuals (Collins & Read, 1990; Hazen & Shaver, 1987, 1994; Keelan, Dion, & Dion, 1998;

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Mikulincer & Nachshon, 1991; Wei, Russel, & Zakalik, 2005). Mikulincer and Nachshon found that avoidant attachment was associated with lower self-disclosure even in response to partner disclosure. In addition, men with ambivalent or avoidant partners were less likely to report having sex at least once a week with their primary partners. This suggests the possibility that, for men in same sex relationships, perceptions and reports of sexual frequency are shaped more by the partner’s style of sexual availability, interpersonal relatedness, and responsiveness than one’s own. These results mirror previous findings, which indicated significant effects of partner characteristics in understanding functioning in heterosexual couples (Brassard et al., 2007; Butzer & Campbell, 2008; Collins & Read, 1990; Mehta et al., 2009). Based on work in heterosexual populations (Brennan & Shaver, 1995; Feeney et al., 1993) and among HIV-positive MSM (Ciesla et al., 2004), we hypothesized that avoidant attachment would be associated with sexual risk taking with casual partners among partnered gay men. The data supported this hypothesis. Avoidant attachment was strongly and positively correlated with the number of casual UAI partners. These results suggest that gay men with avoidant attachment styles may represent important vectors of HIV transmission among their casual partners and to their main partners. There was also a significant partner effect suggesting that men who had avoidantly attached partners also had more casual UAI partners. This may be the result of joint sexual activity in which members of the primary relationship engage in sexual behavior with casual partners together. Risk behavior may also occur independently. This might occur if men with avoidant partners desire a higher level of sexual or emotional intimacy than their partner provides and thusseeks out such intimacy in the context of casual sex partners. While studies in heterosexual samples have found that ambivalent attachment, particularly in women, is associated with decreased sexual risk taking (Bogaert & Sadava, 2002), in the current sample, ambivalent men did not differ significantly from their securely attached counterparts with respect to the number of casual UAI partners. Men’s responses to the AAS were not meaningfully dependent upon their partners, which permitted the use of LCA as an analytic strategy for assigning men to attachment style groups. In their sample of heterosexual couples, Collins and Read (1990) reported small or non-significant between-partner correlations of .34 (p\.01), .19 (p\.05), and .04 (ns) for close, depend, and anxiety, respectively. In their comprehensive review of attachment similarity, Holmes and Johnson (2009) concluded that studies examining partners in long-term relationships generally indicate a preference for individuals with insecure attachment styles to select partners who confirm their attachment expectations, rather than simply seeking attachment similarity. Their review focused on studies of heterosexual

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couples; further studies are needed to better understand partner attachment preferences among gay men in relationships. The relevance of adult attachment to the mental health of partnered gay men is supported generally by existing literature linking insecure attachment to childhood experiences of parental rejection (Landolt et al., 2004), adolescent experiences of peer rejection (Gwadz et al., 2004), and adult reports of negative affect, including:internalizedhomophobia,depression,andguilt(Sherry, 2007). Adult attachment has also been associated with HIV-related stigma and perceived stress among HIV positive men (Riggs et al., 2007). The current findings suggest that adult attachment is also relevant to the sexual health of partnered gay men. Attachment theory–with its focus on behavioral systems activated in infancy, and internal working models developed through initial learning during caregiver interactions that then carryforwardinto adulthood–overlapsconceptually with a broad range of therapeutic orientations (psychodynamic, cognitivebehavioral, systems, etc.) (Gold, 2011). It may, therefore, represent a useful framework for integrating strategies developed in these various approaches. Gold provided a review of integrated interventions organized by a focus on altering internalized schemasandinterpersonal cognitions,conceptssuggestedwithin attachment theory. For example, the concept of the interpersonal schema (Marcotte & Safran, 2002; Safran, 1990) assumes that expectancies about the self-in-relation-to-others are formed through early attachment processes. According to this model, psychopathology is the product of negative interpersonal schemas. These representations are enacted, discussed, and corrected through client-therapist interactions. This integrationist lens suggests innovative possibilities for improving the sexual relationship quality of partnered gay men and reducing their risk of HIV transmission. To the extent that the anticipation of rejection or discomfort with closeness or reliance on others provides motivation for behaviors which endanger one’s health, the health of one’s partners, or the quality of intimate interactions, then interventions which (1) address distorted cognitions related to the expectation of rejection, (2) increase the utilization of skills which adaptively maintain closeness, and (3) reduce discomfort with emotional connection to others may be potentially useful in reducing HIV transmission risk and enhancing the quality of sexual relationships among gay men. Interventions aiming to address such cognitions have been developed (Connors, 2006; Guidano & Liotti, 1983; Marcotte & Safran, 2002; Safran, 1990; Teyber, 2000); however, the efficacy of such interventions in reducing sexual risk behavior has not been investigated. Future research might investigate the efficacy of a cognitive self-schema intervention to alter attachment related behavior, reduce sexual risk, and improve relationship quality among partnered gay men. These findings must be viewed in light of several limitations. First, the results of the LCA presented here should not

Arch Sex Behav (2014) 43:107–117

be interpreted as a direct replication of the cluster structure observed by Collins and Read (1990). While the attachment styles identified in LCA were consistent with previous findings, these data were drawn from a modified version of the AAS. Related to this, AAS subscale reliabilities were in a range that indicates some potential research utility if viewed with caution. Scale reliabilities here are in the range of other studies that have utilized the AAS, and structural modifications (reduction in item number and response scale length) made to accommodate the length of the paper-and-pencil survey may account for some increase in error. Given psychometric considerations, these data should be viewed as a preliminary examination of the relevance of adult attachment to sexual relationship quality and sexual safety intended to encourage future inquiry. Second, we did not have data related to the use of condoms between main partners. These data would have helped to contextualize the degree of sexual risk within couples and future studies should gather this information for main as well as casual partners. Consistent with Brassard et al. (2007) the frequency of main partner sexual activity was conceptualized as an indicator of main partner relationship quality, and not as a direct component of sexual health. Third, we were unable to distinguish between behavior with casual sex partners that occurred independently of, or with a main partner present. These data would have been useful in understanding the context and potential motivation for risk taking behavior. Finally, all items were self-reported on a brief-closed ended survey. While this approach maximized our ability to collect a wide array of information, it may also have limited the depth of participant response. Efforts were taken to ensure participants could complete surveys confidentially. Nevertheless, some participants may have completed the survey in proximity to their partner; thus, our findings should be interpreted with caution. Related to the issue of study participation, some differences were observed between paired and unpaired partnered men. Compared with unpaired participants, paired/matched couples reported significantly higher levels of sexual satisfaction and communication, had greater odds of reporting at least one casual partner, and greater odds of reporting at-least-weekly sex with their primary partner compared with partnered men who we could not match into known dyads. These effects were generally small (Cohen’s d/u * .09-.29). Paired/matched couples had significantly lower attachment anxiety than unpaired partnered men, t(728) = 2.1, p = .03. Again, the magnitude of this difference was small (Cohen’s d = .16). The two groups did not differ on comfort depending on others or comfort with closeness. Future studies should examine whether systematic differences exist between couples who participate in research together compared to partnered men who participate independently of their partners. Such work could meaningfully inform the limits of generalizability of findings from dyadic studies.

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Conclusions While data from samples of heterosexual couples have demonstrated the relevance of attachment to the quality of intimate relationships and sexual health, data from samples of partnered gay men are scarce. Securely attached individuals reported the highest levels of sexual communication and men with securely attached partners were the most likely to report having sex with their partners as least once per week. Finally, avoidant men reported significantly more casual UAI partners than ambivalent or securely attached men. These results suggest that attachment theory may represent a framework for integrating approaches to HIV prevention. Acknowledgments The Sex and Love v3.0 Project was supported by the Hunter College Center for HIV/AIDS Educational Studies and Training (CHEST) under the direction of Jeffrey T. Parsons. The authors acknowledge the contributions of other members of the Sex and Love v3.0 Research Team: David S. Bimbi, Anthony Bamonte, Lauren DiMaria, Gideon Feldstein, Chris Hietikko, Catherine Holder, James P. Kelleher, Brian C. Kelly, Juline Koken, Julia Tomassilli, Brooke Wells, and the DIVAS (Drag Initiative to Vanquish AIDS).

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