Gay and Lesbian Couples in Italy: Comparisons with Heterosexual Couples PAOLO ANTONELLI*  DAVIDE DETTORE* IRENE LASAGNI† DOUGLAS K. SNYDER‡ CHRISTINA BALDERRAMA-DURBIN‡

Assessing couple relationships across diverse languages and cultures has important implications for both clinical intervention and prevention. This is especially true for nontraditional relationships potentially subject to various expressions of negative societal evaluation or bias. Few empirically validated measures of relationship functioning have been developed for cross-cultural applications, and none have been examined for their psychometric sufficiency for evaluating same-sex couples across different languages and cultures. The current study examined the psychometric properties of an Italian translation of the Marital Satisfaction Inventory – Revised (MSI-R), a 150-item 13-scale measure of couple relationship functioning, for its use in assessing the intimate relationships of gay and lesbian couples in Italy. Results for these couples were compared to data from heterosexual married and unmarried cohabiting couples from the same geographical region, as well as to previously published data for gay, lesbian, and unmarried heterosexual couples from the United States. Findings suggest that, despite unique societal pressures confronting Italian same-sex couples, these relationships appear resilient and fare well both overall and in specific domains of functioning compared to heterosexual couples both in Italy and the United States. Keywords: Gay and Lesbian Couples; Same-Sex Couples; Relationship Functioning; Marital Satisfaction; Italian Marriage; Assessment Fam Proc 53:702–716, 2014

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he importance of adult intimate relationships transcends culture and nationality; however, systematic examinations of cultural and national variations in romantic relationship functioning are scarce. Numerous assessment tools have been developed to evaluate intimate relationship functioning, particularly the marital relationship, in the context of a Western culture (Snyder, Heyman, & Haynes, 2008). In the United States (U.S.) and western European countries, considerable empirical evidence documents the health implications of intimate relationships. Couple relationship distress has a high prevalence and strong association with emotional and behavioral disorders in adult partners and their offspring (Bradbury, Fincham, & Beach, 2000; Snyder, Castellani, & Whisman, 2006; Whisman, 2006, 2013). Moreover, couple distress—particularly negative *Department of Health Sciences, University of Florence, Florence, Italy. † The Miller Institute, Florence, Italy. ‡ Department of Psychology, Texas A&M University, College Station, TX.

Correspondence concerning this article should be addressed to: Davide D ettore, Dipartimento di Scienze della Salute, Universit a degli Studi di Firenze, Via di San Salvi 12, Padiglione 26, Florence, Italy; or by email: [email protected]. 702

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communication—has direct adverse effects on cardiovascular, endocrine, immune, neurosensory, and other physiological systems that, in turn, contribute to physical health problems (Gottman & Levenson, 1992; Kiecolt-Glaser & Newton, 2001; Umberson, Williams, Powers, Liu, & Needham, 2006). Clinicians and researchers alike have an increasing responsibility to enhance their cultural awareness and sensitivity to issues having such systemic mental health implications. Because the majority of relationship assessment techniques has been developed and validated primarily using Western community and clinic samples, there persists a striking paucity of psychometrically appropriate assessment tools to evaluate adult intimate relationships in other cultures.

The Prevalence and Social Status of Same-Sex Relationships in Italy A recent survey published by the National Institute of Statistics in Italy (Istituto Nazionale di Statistica [ISTAT], 2012) for the year 2011 documents both the prevalence of same-sex relationships in Italy as well as the social biases that couples in these relationships confront. In the area of central Italy alone (an area including the four statistical regions of Lazio, Marche, Tuscany, and Umbria—and the cities of Florence and Rome— with a total population of approximately 12 million), about 1 million adults declared themselves as either homosexual or bisexual, and another 2 million adults reported that they had “fallen in love” or felt a sexual attraction to others of their same sex. Attitudes toward gay males and lesbians reported in this same survey showed deeply divided and conflicted opinions among the general Italian population. For example, a majority (60%) felt that it was acceptable for persons to have emotional and sexual relationships with someone of the same sex, and about the same percentage believed that homosexuals in Italy experienced unfair discrimination. A smaller percentage (44%) expressed that homosexuals should have the opportunity to marry and should have the same legal rights as heterosexual couples. From a contrasting perspective, the majority of respondents (56%) in the ISTAT 2011 survey believed that homosexuals would be better accepted if they were “more discreet,” and 30% stated that the best approach was for them not to tell others of their sexual orientation. In addition, many respondents stated that having homosexuals in specific jobs or professions created problems for society—with significant percentages reporting that it was not acceptable for a homosexual to be an elementary school teacher (41%), physician (28%), or politician (25%). Indeed, many participants in the same survey who identified themselves as homosexual or bisexual reported experiencing precisely these forms of prejudices—including discrimination at their school or university (24%), during job searches (30%), or at the work place (22%). Considering these three domains together, 40% of homosexuals or bisexuals reported one or more incidents of discrimination—with this percentage rising to 54% when additional domains were considered such as searching for a house, gaining access to health services, or dealing with public agencies. The overwhelming majority of homosexuals or bisexuals (80%) avoided telling their parents about their sexual orientation—with most (77%) sharing this information only with their closest friends.

Cross-Cultural Similarities and Differences in Factors Impacting Gay and Lesbian Couples In many important respects, these results from the ISTAT 2011 survey mirror important findings regarding gay and lesbian couples in previous studies conducted in the U.S. documenting discrimination based on sexual orientation and social stressors specific to lesbians and gay men including family rejection and lack of support (Gotta et al., 2011; Kurdek, 2005; Newcomb & Mustanski, 2010; Peplau & Fingerhut, 2007). Other Fam. Proc., Vol. 53, December, 2014

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gay-related stressors involve the need to hide one’s sexual orientation, fear of being exposed as homosexual, violence and harassment, lack of societal acceptance, and discrimination. In Italy, individuals in same-sex relationships do not have the choice of a legal marriage, and they are often socially stigmatized and marginalized (Antonelli & Dettore, 2013; Barbagli & Colombo, 2007). This social and political context renders same-sex couples legally vulnerable during times of crisis (e.g., medical emergencies or the death of a partner) when families of origin, with legal privilege over their legally “single” relative, may refuse to honor or even acknowledge an individual’s sexual identity or same-sex relationship (Riggle, Rostosky, & Horne, 2010). Under these circumstances, such relationships can effectively be negated by relatives and institutions. At the same time, there are important differences in social and legal factors that potentially impact gay and lesbian couples in Italy in unique and adverse ways. Both the Italian religious and legal cultures present particularly challenging circumstances to same-sex couples. Italy is now one of the few European countries where same-sex marriage or civil unions are not allowed, mostly because of the strong influence of the Roman Catholic Church and more conservative religious attitudes of Italians. In a large Italian survey, 90% of respondents involved in same-sex relationships reported numerous instances of negative discriminatory behaviors toward Italian homosexual and bisexual men and women in everyday life, adverse depictions in mass media, and widespread heterosexism (Barbagli & Colombo, 2007; Graglia, 2009). These findings stand in sharp contrast to survey findings in Spain, which shares numerous sociocultural similarities with Italy, but which in 2005 became the third country in the world (after the Netherlands and Belgium) to legalize same-sex marriage. In a survey conducted by the Spanish government-run Center for Sociological Investigations in 2005, 86% of Spaniards favored legalizing same-sex marriage (Platero, 2007), compared to only 41% of Italians in a similar study (Barbagli & Colombo, 2007). Against this backdrop of deeply conflicted views regarding homosexuality in Italy and the relationship stresses that inevitably accompany exposure to such social prejudices, an important question is to what extent same-sex relationships in Italy succumb to such stressors or exhibit relationship difficulties when compared to their married or cohabiting Italian heterosexual couples counterparts?

Assessing Intimate Adult Relationships Across Culture and Sexual Orientation Assessing and comparing adult intimate relationships across cultures requires a common measurement tool with evidence of psychometric sufficiency in the different targeted groups. This same principle applies when the “culture” is defined not by geographic region, language, or ethnicity—but rather by other characteristics potentially influencing relational dynamics such as sexual orientation. Most of the empirical research on assessment strategies for adult intimate relationships has been conducted predominantly with the U.S. or Western European samples—with relatively little research comparing psychometric features of relationship measures across language or relationship structure. An exception to this generalization has been previous research involving cross-cultural adaptations of the Marital Satisfaction Inventory – Revised (MSI-R; Snyder, 1997), as well as the application of this measure to the study of nontraditional (unmarried cohabiting or same-sex) couples. The MSI-R is a 150-item self-report measure of relationship functioning composed of 13 scales designed to evaluate the nature and the intensity of relationship distress in various distinct areas of partners’ interaction. An additional abbreviated 10-item screener, the Marital Satisfaction Inventory – Brief form (MSI-B), has been empirically derived from the full-length version of the MSI-R to detect relationship discord and to classify couples into clinically meaningful groups of distressed versus nondistressed www.FamilyProcess.org

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couples (Whisman, Snyder, & Beach, 2009). Previous research has supported the internal consistency, discriminative validity, and structural equivalence of published adaptations of the MSI-R in German, Spanish, Korean, and Arabic-speaking samples (BalderramaDurbin, Snyder, & Semmar, 2011; Gasbarrini, Snyder, Willson, & Newman, 2010; Snyder et al., 2004). Unpublished adaptations of the MSI-R have also been developed for use with Italian, French, Russian, Chinese, and Japanese-speaking couples. Cross-cultural test adaptation requires multiple levels of methodological consideration to accrue evidence supporting psychometric adequacy of the adapted measure. The MSI-R also comprises one of the very few evidence-based measures of relationship functioning examined for its suitability with same-sex couples. In a previous study of gay male and lesbian couples in the United States (Means-Christensen, Snyder, & Negy, 2003), the MSI-R scales retained high levels of internal consistency across traditional married and nontraditional samples, and specifically across gay and lesbian couples. Moreover, factor analyses indicated high degrees of convergence in relations among overall relationship satisfaction and specific domains of interaction across married heterosexual, cohabiting, and gay and lesbian couples. Overall, cohabiting same-sex and opposite-sex couples were more alike than different, and more similar to married heterosexual couples from the general community than to clinical samples of distressed couples. Results of these previous studies suggest the potential merits of extending the MSI-R to the study of gay and lesbian couples in Italy—a group for whom national survey data suggest a high level of exposure to social prejudices and stressors, and about whom very little is known from research adopting standardized measures of relationship functioning. Based on this foundation, the present study had three objectives: (1) to examine the psychometric characteristics of the MSI-R when adapted for use with both heterosexual and same-sex Italian couples; (2) to compare gay male and lesbian Italian couples to their heterosexual cohabiting or married Italian counterparts; and (3) to compare findings for each of the Italian subgroups (heterosexual married or cohabiting, gay male or lesbian couples) to previous findings obtained for similar subgroups in the United States.

METHODS Participants Gay male and lesbian couples A sample of 30 gay male couples and 30 lesbian couples was recruited from gay and lesbian communities in the provinces of Tuscany in central Italy, including the major metropolitan area of Florence, the mid-size towns of Pistoia, Prato, Lucca, and Siena, and the semi-rural small towns in the surrounding areas. Gay and lesbian couples initially were informed of the study through gay and lesbian community organizations, flyers, and advertisements posted in clubs and bars serving the gay and lesbian community, and by networks of friends and subsequent word of mouth by previous participants. Each couple contacted the investigators for study materials and an appointment was scheduled during which research assistants went to the homes of the participants, reviewed the informed consent procedures, and left study materials for participants to complete. Research assistants returned to the participants’ homes later that day to pick up the study materials and to answer any questions. Married and unmarried heterosexual couples A sample of 30 married couples and 30 unmarried couples was recruited from the same provinces of Tuscany in Italy from which the gay male and lesbian couples were sampled. Recruitment procedures were similar and included flyers and advertisements posted Fam. Proc., Vol. 53, December, 2014

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throughout the community, and networks of friends and subsequent word of mouth by previous participants. These participants contacted the investigators, an appointment was scheduled, and research assistants delivered study materials to their homes and retrieved them later that same day. Across all groups, participants averaged 14.8 years of education (SD = 3.6) and there were no differences among the four subgroups, F(3, 236) = 1.04, p = .38. As one might anticipate, there were significant differences across subgroups in age, F(3, 236) = 41.63, p < .01, with heterosexual married and unmarried couples comprising the oldest and youngest groups (M ages = 44.0 and 28.5 years, respectively) and gay and lesbian couples falling between these two extremes (M ages = 36.2 and 29.6 years, respectively). Heterosexual married and unmarried couples had been in their relationship longer (M duration = 13.1 and 6.1 years, respectively) compared to gay and lesbian couples (M duration = 3.8 years and 3.6 years, respectively), F(3, 236) = 22.26, p < .01.

Measure The MSI-R (Snyder, 1997) is a 150-item, true–false, self-report measure of relationship functioning designed to identify both the nature and intensity of distress in distinct areas of partners’ interaction. The inventory is administered to both partners separately and requires approximately 25 minutes to complete. The MSI-R is composed of 13 profile scales: two validity scales, one global distress scale, and 10 additional scales assessing specific dimensions of the couple’s relationship. Individuals’ responses to each item are scored along these scales and are plotted on a standard profile sheet based on gender-specific norms using normalized T-scores. Previous studies have supported MSI-R scales’ internal consistency (M = .81), 6-week temporal stability (M = .79), and discriminative validity (M effect size using Cohen’s d = 1.07 when contrasting community and clinical couples). Actuarial tables linking scale scores to descriptors of the couple’s relationship provided by clinicians and both spouses have shown the MSI-R scales to relate to a broad range of external criteria consistent with their interpretive intent (Snyder, 1997). In the present study, the Italian MSI-R was developed through an iterative process of back-translation by a team of bilingual psychologists with expertise in both relationship functioning and test translation.1 MSI-R scale names, abbreviations, and brief descriptions are as follows: ● Inconsistency (INC): A validity scale assessing the individual’s consistency in responding to item content (20-item pairs with high scores reflecting greater inconsistency). ● Conventionalization (CNV): A validity scale assessing individuals’ tendencies to distort the appraisal of their relationship in a socially desirable direction (10 items with high scores reflecting denial of common relationship shortcomings). ● Global distress (GDS): This measures individuals’ overall dissatisfaction with the relationship (22 items). ● Affective communication (AFC): This evaluates individuals’ dissatisfaction with the amount of affection and understanding expressed by their partner (13 items). ● Problem-solving communication (PSC): This assesses the couple’s general ineffectiveness in resolving differences (19 items). ● Aggression (AGG): This measures the level of intimidation and physical aggression experienced by respondents from their partner (10 items).

1

The Italian MSI-R used in this study was developed through an iterative process of multiple translations and back-translations by Raffaella Iafrate, Silvia Donato, and Anna Bertoni at the Dipartimento di Psicologia, Universit a Cattolica del Sacro Cuore, Milan, Italy.

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● Time together (TTO): This evaluates the couple’s companionship as expressed in time shared in leisure activity (10 items). ● Disagreement about finances (FIN): This measures relationship discord regarding the management of finances (11 items). ● Sexual dissatisfaction (SEX): This assesses dissatisfaction with the frequency and quality of intercourse and other sexual activity (13 items). ● Role orientation (ROR): This evaluates the respondent’s advocacy for a traditional versus nontraditional orientation toward marital and parental gender roles (12 items with high scores reflecting a nontraditional, more egalitarian orientation). ● Family history of distress (FAM): This reflects the disruption of relationships within the respondent’s family of origin (9 items). ● Dissatisfaction with children (DSC): This assesses the relationship quality between respondents and their children as well as parental concern regarding the emotional and behavioral well-being of their children (11 items). ● Conflict over child rearing (CCR): This evaluates the extent of conflict between partners regarding child rearing practices (10 items). In the present study, both of the child-related scales (DSC and CCR) were omitted entirely because they applied only to a minority of the Italian married couples and none of the couples in the other three groups; similarly, the role orientation (ROR) scale was administered only to the married and unmarried heterosexual couples, because of its limited applicability to same-sex couples.

RESULTS A series of analyses was conducted to assess the psychometric and structural qualities of the Italian MSI-R profile scales including internal consistency and factorial equivalence across heterosexual and same-sex couples subgroups.

Internal Consistency Results of internal consistency analyses for the MSI-R scales for Italian heterosexual and same-sex couples are presented in Table 1. For evaluation purposes, these alpha (a) coefficients are compared with internal consistency findings for the U.S. standardization sample of 2,040 married individuals (Snyder, 1997) and for the U.S. samples of 72 cohabiting and 118 gay and lesbian respondents (Means-Christensen et al., 2003). For the Italian married couples, the a coefficients ranged from .73 to .88 (M = .80); for Italian heterosexual unmarried couples, a coefficients ranged from .57 to .82 (M = .71). For the Italian gay and lesbian couples, a coefficients ranged from .56 to .83 (M = .72). Overall, these internal consistency coefficients for the Italian subgroups compare favorably (albeit for some individual scales slightly lower) to the analogous U.S. samples of married, cohabiting, and gay/lesbian couples (mean a coefficients of .83, .81, and .83, respectively). In general, for unmarried heterosexual or same-sex Italian couples, MSI-R scales assessing narrower domains of relationship functioning (e.g., finances or leisure time together) tended to have slightly lower a coefficients compared to the remaining scales—a finding not generalizable to their U.S. counterparts.

Scale Intercorrelations and Factor Structure MSI-R scale intercorrelations for Italian couples sampled in this study are presented in Table 2. Results for heterosexual participants are shown above the diagonal, and results for gay and lesbian respondents are shown below the diagonal. In general, these results Fam. Proc., Vol. 53, December, 2014

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TABLE 1 Internal Consistency Coefficients for MSI-R Scales for the United States and Italian Married, Cohabiting, and Gay and Lesbian Couples

United States

Italy

Scales

Married

Cohabiting

Gay/Lesbian

Married

Cohabiting

Gay/Lesbian

INC CNV GDS AFC PSC AGG TTO FIN SEX ROR FAM M n

n/a .82 .92 .84 .88 .80 .79 .78 .84 .84 .78 .83 2,040

n/a .79 .93 .79 .89 .75 .77 .77 .82 .79 .80 .81 72

n/a .83 .91 .78 .89 .84 .80 .82 .85 n/a .79 .83 118

n/a .83 .88 .79 .86 .78 .73 .80 .81 .77 .78 .80 60

n/a .72 .73 .63 .65 .79 .64 .57 .82 .77 .76 .71 60

n/a .74 .79 .67 .81 .77 .58 .56 .77 n/a .83 .72 120

Note. INC = inconsistency; CNV = conventionalization; GDS = global distress; AFC = affective communication; PSC = problem-solving communication; AGG = aggression; TTO = time together; FIN = disagreement about finances; SEX = sexual dissatisfaction; ROR = role orientation; FAM = family history of distress; n/a = not applicable.

closely parallel findings for the U.S. standardization sample of 1,020 couples (Snyder, 1997). That is, for both the Italian heterosexual and same-sex couples, broad-band measures of relationship functioning (e.g., global distress, affective, or problem-solving communication) tend to correlate highly with each other; by contrast, more narrow-band measures of relationship functioning (e.g., finances, aggression, sexual satisfaction) tend to correlate moderately with global distress, and only modestly with each other. Scales assessing role orientation and family history of distress are only modestly related, if at all, to overall relationship functioning. Because previous research (Balderrama-Durbin et al., 2011; Gasbarrini et al., 2010) has suggested a one-factor solution for MSI-R scales explicitly linked to a hypothesized latent factor of relationship discord (i.e., GDS, AFC, PSC, AGG, TTO, FIN, and SEX), confirmatory factor analysis (CFA) was used to test the goodness-of-fit for these scales to a one-factor solution in the four Italian subgroups. Four model goodness-of-fit indices were used to evaluate fit of the data—including the root mean square error of approximation (RMSEA; Steiger, 1990), the standardized root mean square residual (SRMR; Hu & Bentler, 1998); the nonnormed fit index (NNFI; Bentler & Bonett, 1980), and the comparative fit index (CFI; Bentler, 1990). Models are deemed to show reasonable fit for RMSEA values ≤.05 (with values ≥.10 indicating poor fit); SRMR values ≤.08; NNFI ≥ .95; and CFI ≥ .90 (Bollen & Long, 1993). Results of the CFA for the four Italian subgroups are presented in Table 3; for comparison purposes, results from a one-factor CFA using the same MSI-R scales for the U.S. standardization sample of 1,020 couples are also shown. Overall, results from these CFAs provide strong evidence for a one-factor solution suggesting a unitary latent construct of relationship distress for the Italian gay and lesbian couples, as well as the Italian unmarried cohabiting couples—with each of these groups meeting suggested criteria on the SRMR and CFI goodness-of-fit indices, and approaching suggested criteria on the RMSEA and NNFI criteria. By contrast, although the subgroup of Italian married couples met the suggested criterion for a one-factor solution on the SRMR index, it failed to meet or www.FamilyProcess.org

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TABLE 2 Intercorrelations Among MSI-R Scales for Italian Heterosexual and Gay and Lesbian Couples

Scale

CNV

GDS

AFC

PSC

AGG

TTO

FIN

SEX

ROR

FAM

CNV GDS AFC PSC AGG TTO FIN SEX ROR FAM

– .58 .64 .49 .27 .57 .21 .38 – .29

.63 – .46 .40 .26 .47 .28 .35 – .25

.65 .53 – .55 .26 .43 .16 .36 – .20

.62 .43 .66 – .46 .40 .11 .32 – .19

.42 .39 .44 .49 – .27 .21 .17 – .00

.39 .41 .48 .42 .02 – .25 .26 – .21

.26 .40 .34 .34 .39 .32

.49 .38 .45 .52 .18 .28 .22 – – .06

.07 .10 .21 .30 .32 .24 .17 .03 – –

.15 .29 .17 .11 .13 .20 .17 .07 .17 –

– .20 – .02

Note. CNV = conventionalization; GDS = global distress; AFC = affective communication; PSC = problem-solving communication; AGG = aggression; TTO = time together; FIN = disagreement about finances; SEX = sexual dissatisfaction; ROR = role orientation; FAM = family history of distress. Results for heterosexual participants (n = 120) are above the diagonal; results for gay and lesbian participants (n = 120) are below the diagonal.

TABLE 3 Goodness-of-Fit Indices for One-Factor Confirmatory Factor Analysis for Italian Heterosexual and Gay and Lesbian Couples, and U.S. Standardization Sample

Sample Italy Married couples Cohabitating couples Gay couples Lesbian couples United States Standardization sample

RMSEA

SRMR

NNFI

CFI

0.207 0.087 0.112 0.056

0.075 0.071 0.069 0.060

0.746 0.846 0.867 0.944

0.830 0.898 0.911 0.963

0.081

0.026

0.964

0.976

Note. For Italian subgroups, n = 60 each; for U.S. standardization sample, n = 2,039. RMSEA = root mean square error of approximation; SRMR = standardized root mean square residual; NNFI = nonnormed fit index; CFI = comparative fit index.

approach the suggested criteria for the RMSEA, NNFI, or CFI criteria—in contrast to their counterpart married respondents in the U.S. standardization sample. This indicates that reports of relationship functioning by Italian married respondents across diverse domains are more differentiated, and less linked to a single underlying dimension of global relationship affect, than for the other groups.

Group Mean Comparisons Mean normalized T-scores on each of the MSI-R scales for the four Italian subgroups are presented in Table 4. For comparison purposes, in the U.S. standardization sample, normalized T-scores have a mean of approximately 50 and a standard deviation of about 10. In addition, based on standard errors of difference for these scales (Snyder, 1997), a difference of approximately 6 points (i.e., T-scores ≤44 or ≥56) would be necessary to conclude with roughly 68% confidence that an observed mean score for the Italian subgroups differed meaningfully (reliably) from the U.S. standardization sample. Results in Table 4 confirm that each of the four Italian subgroups closely approximate the U.S. standardization sample of heterosexual married couples, with only a small Fam. Proc., Vol. 53, December, 2014

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TABLE 4 Mean MSI-R Scale Scores for Italian Married, Cohabiting, Gay, and Lesbian Couples

INC CNV GDS AFC PSC AGG TTO FIN SEX ROR FAM

Married

Cohabiting

Gay

Lesbian

54.6 54.3 52.6 50.5 49.2 50.9 49.5 48.0 48.9 56.8 50.0

52.4 54.0 51.9 48.8 49.6 48.3 47.6 47.8 48.9 61.4 48.6

49.0 53.7 51.1 49.0 46.6 50.5 46.2 50.0 44.7 – 51.7

49.3 57.6 51.5 44.5 48.4 49.3 44.1 47.9 45.8 – 50.8

t(238) 3.76* 1.35 1.10 2.93* 1.93 0.24 3.57* 1.07 3.44* – 1.52

Effect Size for Sexual Orientation 0.49 0.17 0.14 0.38 0.25 0.03 0.46 0.14 0.44 – 0.20

Note. INC = inconsistency; CNV = conventionalization; GDS = global distress; AFC = affective communication; PSC = problem-solving communication; AGG = aggression; TTO = time together; FIN = disagreement about finances; SEX = sexual dissatisfaction; ROR = role orientation; FAM = family history of distress. For each group, n = 60. Univariate t tests and related effect sizes reflect comparisons of heterosexual versus same-sex couples; positive t values and effect sizes indicate lower means (lower distress) for same-sex couples. *p < .01.

number of differences—and these being of modest magnitude. Specifically, for only three of 42 Italian subgroup means did the average MSI-R scale differ meaningfully from the U.S. standardization sample. Two of these differences reflected both married and unmarried heterosexual Italian couples showing a less traditional gender role orientation (higher ROR score) than their U.S. counterparts (M scores of 56.8 and 61.4, respectively); indeed, these higher scores on ROR are similar to findings for unmarried cohabiting heterosexual U.S. couples reported by Means-Christensen et al. (2003). The third difference reflected Italian lesbian respondents describing their relationship in a more “idealized” manner on CNV (M score of 57.6) compared to the U.S. standardization group. Multivariate analysis of variance (MANOVA) confirmed overall differences across the four Italian subgroups on these MSI-R scales, F(30, 677) = 3.48, p < .01. Further univariate tests compared heterosexual with same-sex couples both in terms of statistical significance (t tests) and effect size (Cohen’s d). In each instance of statistical significance (p < .01) and where results approached a “medium” effect size (d between .35 and .65), gay and lesbian couples reported greater relationship satisfaction (i.e., lower MSI-R scores) compared to Italian heterosexual couples. Specifically—on measures assessing quality of leisure time together, sexual satisfaction, and affective communication (AFC), mean scores for the Italian gay and lesbian couples approximated a normalized T-score of 45— showing lower distress compared not only to the Italian heterosexual couples, but also approaching significantly lower distress in these domains compared to the U.S. standardization sample of married couples.

DISCUSSION The development and subsequent use of empirically validated assessment tools are critical in guiding diagnosis and clinical decision making. Although couple relationship distress has important implications for a variety of mental and physical health problems, both research and clinical assessment of relationship functioning has been limited primarily to heterosexual populations—and largely to those in English-speaking countries www.FamilyProcess.org

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—restricting generalizability to other cultures and nontraditional relationship styles. The present study is only the second to apply a multidimensional measure of relationship functioning to gay and lesbian couples, and is the first to do so outside the United States. Overall, findings indicated important similarities in MSI-R test characteristics across Italian and the U.S. samples, and across heterosexual and same-sex samples, supporting further use of this instrument with these groups. Specifically, the Italian MSI-R demonstrated moderate to strong internal consistency across scales, with a coefficients for Italian married couples virtually identical to those for their U.S. counterparts, and a coefficients for the Italian nontraditional (cohabiting or gay/lesbian couples) only modestly lower. Moreover, confirmatory factor analyses indicated that for each of the Italian nontraditional subgroups, MSI-R scales of relationship distress were strongly linked to a single underlying latent factor, similar to findings for the U.S. standardization sample. Interestingly, Italian married couples in this study showed greater differentiation in their appraisals of relationship distress across diverse domains, with less satisfactory fit to a one-factor model compared to the other groups. Although the source of this cultural difference for Italian versus the U.S. married couples remains unclear, correlations between MSI-R scales reflecting specific dimensions of relationship functioning (AFC, PSC, AGG, TTO, FIN, SEX) correlated less strongly with overall relationship distress (GDS) in the Italian married couples (r = .42–.59; M = .52) compared to the U.S. standardization sample (r = .53–.76; M = .63). Evaluation of MSI-R mean scores indicated that each of the four Italian subgroups of both heterosexual and same-sex couples was far more similar to, than different from, the U.S. standardization sample, with only a few statistically reliable differences reflecting a less traditional gender role orientation in the Italian heterosexual couples. Effect size comparisons among the four Italian subgroups showed that, where differences between heterosexual and same-sex couples existed, these actually favored greater relationship satisfaction among the same-sex respondents in domains of AFC, leisure time together, and sexual functioning. Interestingly, each of these three scales (AFC, TTO, and SEX) reflects different aspects of relationship intimacy (emotional, behavioral, and sexual)— suggesting that same-sex relationships are promoted and sustained particularly by their intimate bonds. In Italy, under the duress of explicit discrimination toward homosexuals, such intimate bonds may be essential for the well-being and durability of same-sex couples. That is, given the dearth of social support outside their relationship, gay and lesbian partners may be compelled to promote and sustain even greater support within their relationship. Overall, these findings replicate previous findings by Means-Christensen et al. (2003) in their study of nontraditional couples in the United States. In that study, results using the MSI-R similarly indicated that same-sex couples and cohabiting unmarried heterosexual couples were more alike than different, and were more similar to nondistressed samples of married heterosexual couples from the general community than to couples in therapy. Findings of that study also indicated that lesbian participants had particularly high levels of relationship satisfaction, exceeding reports of both emotional and behavioral intimacy compared to gay male respondents and unmarried women in cohabiting heterosexual relationships. Italian lesbian respondents were also more likely to describe their relationship in a more “idealized” manner on CNV compared to the U.S. standardization group. In a recent Italian study, a group of 32 lesbian mothers was compared with a group of 44 heterosexual parents regarding their beliefs and behaviors related to three domains of parenting (social, didactic, and disciplinary). Results showed a high degree of convergence in the parenting style between lesbian mothers and heterosexual parents (Elia, Antonelli, & D ettore, 2013). Findings from the present study are also consistent in important respects to other studies from the United States regarding same-sex couples using other measures of Fam. Proc., Vol. 53, December, 2014

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relationship functioning. In terms of overall relationship satisfaction and functioning, cross-sectional studies typically find that the correlates of relationship quality are highly similar for gay and lesbian couples, compared to heterosexual couples (Kurdek, 2005; Peplau & Cochran, 1981). Longitudinal studies (e.g., Kurdek, 1998) have indicated that same-sex relationships operate on essentially the same principles as heterosexual relationships. Relationship satisfaction and stability in gay and lesbian relationships have been related to similar emotional qualities as in heterosexual relationships, based on recordings of physiological responses to discussions of everyday events and conflict-resolution tasks (Gottman, Levenson, Gross et al., 2003) and observational comparisons of heterosexual and same-sex couples’ communication (Gottman, Levenson, Swanson et al., 2003; Julien, Chartrand, Simard, Bouthillier, & Begin, 2003). Indeed, in the latter Gottman study, findings indicated that, relative to heterosexual partners, gay and lesbian partners began their discussions more positively, were more likely to maintain a positive tone, and resolved conflict more positively than married partners. Results from the current study also correspond in interesting ways to previous findings regarding specific domains of relationship functioning. For example, lesbian participants in Italy scored lower on the AFC scale of the MSI-R, indicating higher levels of satisfaction with emotional understanding and responsiveness in their relationship compared to gay male or heterosexual respondents; they also scored higher on the CNV scale, reflecting more idealized depictions of their relationship. Both findings are consistent with previous studies from the United States showing that lesbian partners report more intimacy compared to married spouses (Kurdek, 1998). In the present study, both gay and lesbian partners also obtained lower scores on the TTO scale of the MSI-R, indicating higher satisfaction with the quality of leisure time together, compared to heterosexual respondents. Same-sex respondents in the Italian sample also reported lower scores on the SEX scale, indicating greater satisfaction with physical intimacy, compared to Italian married and cohabiting heterosexual couples; previous studies in the United States have suggested that gay men have sex more frequently and lesbians less frequently than heterosexual married couples (Blumstein & Schwartz, 1983; Peplau, Fingerhut, & Beals, 2004; Solomon, Rothblum, & Balsam, 2005), although the linkage of sexual frequency to overall satisfaction with physical intimacy was not specified. Separate from the MSI-R, same-sex partners in the present study reported a shorter mean duration of their relationship compared to heterosexual participants, consistent with characteristics of same-sex samples in previous studies in the United States (e.g., Gotta et al., 2011). Previous literature from the United States suggests that partners in same-sex relationships experience less social support for their relationships and fewer barriers to ending their relationship; although some gay and lesbian couples raise children, the majority do not (Simons & O’Connell, 2003), thereby removing another significant barrier to dissolution. Despite the overall relationship health of gay and lesbian couples sampled in the present study, there is no doubt that many same-sex couples—particularly in Italy—experience tremendous social challenges to their survival and that a significant percentage succumb to these pressures in developing relationship distress or experiencing dissolution. In a previous qualitative study of Italian gay and lesbian couples (Antonelli, Stefanile, & D ettore, 2010), participants emphasized challenges posed by frequent rejection by members of the family of origin, as well as societal prohibitions reflected in deeply rooted cultural prejudices against homosexual relationships and both legal and economic discrimination. Building on prior models of minority stress (e.g., Meyer, 2003), emerging findings indicate that the impact of negative (homophobic) self-attitudes on psychological distress is partially mediated by experiences of active discrimination, lack of social support, and www.FamilyProcess.org

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reluctance to self-disclose—and that the effect of nonself-disclosure is further mediated by the absence of social support (Antonelli, 2012). Clinical implications suggest the potential utility of building more effective instrumental as well as emotional coping strategies particularly around discriminatory experiences, expanding bases of social support, as well as promoting a self-expressive language specifically around emotional experiences related to the gay or lesbian lifestyle. Limitations of the current study bear noting. Although this is among the few studies examining gay male and lesbian couples in Italy, and the first to study either same-sex or heterosexual couples in Italy using a standardized measure allowing comparison to a variety of other cross-national and cultural groups, the current sample size and sampling strategy were admittedly less than optimal. First, because of the voluntary nature of participation and self-selection into the study sample, couples experiencing more acute levels of distress may have been underrepresented, regardless of marital or cohabiting status and sexual orientation. Second, because of their vulnerability to social and legal discrimination, gay and lesbian couples may have been less willing to volunteer for this study—a methodological limitation in working with minority populations and with gay and lesbian couples in particular, noted previously in the literature (Kurdek, 2005). Third, similar to some other studies in the United States (e.g., Gotta et al., 2011), heterosexual couples in this study had been in their relationship longer compared to gay and lesbian couples, and this may have influenced participants’ perceptions and reporting of relationship experiences. Finally, it should be noted that the forms and levels of discrimination impacting gay and lesbian couples in the Tuscan region of Italy do not necessarily generalize to other regions of Italy, potentially further limiting the generalizability of these findings. For example, in the Italian national ISTAT survey (2012) described earlier, 67% of respondents in central Italy expressed opinions that homosexual emotional and sexual relationships were either “very” or “quite” acceptable, compared to only 49% of respondents from Southern Italy. Quantitative findings from same-sex couples in this sample were not complemented by or linked to qualitative data that could have emerged by supplementing the self-report strategy in this study with a clinical interview of couples inquiring further about relationship dynamics and specific social prejudices and related stressors experienced by these participants. Similarly, both the size of the sample and measurement design did not permit examination of potential moderators of relationship distress unique to gay and lesbian relationships—such as family rejection or societal discrimination at economic or legal levels, stigma consciousness, or internalized homophobia. Previous studies in both the United States (as reviewed by Kurdek, 2005) and in Italy (Antonelli, 2012) have indicated that the adverse impacts of social and legal discrimination as well as family rejection may be buffered, in part, by the breadth and quality of other social support. Indicators of these stressors and actual experiences of discrimination, as well as potential buffers such as social support and individual or dyadic coping strategies, were not evaluated in the present study and merit further study for their influences in cross-cultural comparisons. Despite these limitations, the current study expands the scarce empirical literature regarding cross-cultural comparisons of adult intimate relationships and even scarcer empirical literature comparing heterosexual with same-sex couples. Overall, findings demonstrate considerable similarity of experiences in adult intimate relationships among Italian couples independent of sexual orientation, as well as their similarity in relationship functioning to samples of both traditional and nontraditional couples differing in language and nationality. These findings suggest that, when nontraditional Italian couples do obtain elevated MSI-R scale scores reflecting relationship distress, these can be attributed at least in part to actual relationship difficulties, rather than entirely to marital status or sexual orientation. That is, in clinical assessment with nontraditional Italian couples, interpretive ranges on the MSI-R scales suggesting “possible or moderate Fam. Proc., Vol. 53, December, 2014

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problem” and “definite or extensive problem” likely have similar meaning when applied to these couples as when applied to married heterosexual couples. Similarly, for either screening purposes or for research with gay and lesbian couples in Italy, an abbreviated 10-item screening scale derived from the full-length MSI-R is likely to demonstrate similar levels of sensitivity and specificity as found in the United States for detecting relationship discord and for classifying couples into clinically meaningful groups of distressed versus nondistressed couples (Whisman et al., 2009). As with heterosexual married couples, clinical findings from the MSI-R should be carefully integrated with other interview and observational findings in developing a case formulation and comparing partners’ descriptions of their relationship with each other or with other clinical and nondistressed groups. Although previous studies in the United States suggest that same-sex relationships function similarly to heterosexual relationships in many respects (Kurdek, 1998), it is also critical to understand ways in which gay and lesbian relationships are different from each other and from those of heterosexual couples (Kurdek, 2005) if one is to engage in meaningful and efficacious interventions. Green and Mitchell (2008) have grouped special developmental challenges facing same-sex couples under three broad categories: (1) coping with lesbian and gay minority stress; (2) resolving relational ambiguity in the areas of commitment, boundaries, and gender-linked behaviors; and (3) developing a “family of choice” (a cohesive network of social support). Research with nontraditional couples, particularly research emphasizing clinical assessment and intervention techniques, remains in its infancy. Relatively few studies of gay male and lesbian couples have used married or unmarried heterosexual couples as a comparison group; failure to do so precludes the ability to disentangle significant effects resulting from marital status, gender, sexual orientation, and the interaction of these factors. In addition, much of the research with couples generally, and with same-sex couples specifically, has been conducted with English-speaking Caucasians age 25–40. Hence, future studies would benefit from a more systematic sample of nontraditional couples across ethnicity, language and culture, age, socioeconomic status, and related domains. Little is known from a developmental lifespan perspective regarding gay and lesbian couples; even less is known regarding cultural differences in gender role socialization and heterosexist biases and their impact on same-sex couples’ relationship functioning. Separate from sociocultural stressors exerting adverse impact on gay and lesbian couples, little is known about potential buffers or forces that help to stabilize these relationships. It is unlikely that Italian gay and lesbian couples will soon have the option to marry; hence, they will need to continue to rely less on institutional forces to maintain their relationships and more on such processes as commitment and support from close friends. Despite a modest trend toward increased parenthood among gay male and lesbian couples through adoption, birth, or custody from previous relationships, almost nothing is known about the impact of child rearing on same-sex couples in either the United States or Italy compared to the literature examining the impact of children on traditional married couples across the family life cycle. As more same-sex couples pursue the opportunity to rear children, efforts to expand research on the family life cycle with this population will become increasingly important. Finally, compared to controlled outcome studies of clinical interventions with heterosexual couples, empirical findings regarding couple therapy for same-sex couples are virtually nonexistent. Until relationship therapy with gay and lesbian couples undergoes the same scrutiny as therapy with heterosexual couples, clinicians working with same-sex couples are left to draw on empirically supported interventions for relationship issues and processes common to couples regardless of sexual orientation, while making every effort to recognize and contend with the unique developmental and sociocultural stressors their gay and lesbian clients confront in both their individual and relationship lives. Appropriate interventions begin with valid and reliable assessment. www.FamilyProcess.org

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REFERENCES Antonelli, P. (2012). Il minority stress nella popolazione gay e lesbica italiana: il ruolo dell’omonegativit a interiorizzata [Minority stress in the Italian gay and lesbian population: The role of internalized homonegativity]. Unpublished Doctoral Dissertation, Universit a degli Studi di Firenze, Firenze, Italia. Antonelli, P., & D ettore, D. (2013). La coppia omosessuale oggi [The homosexual couple today]. Rivista di Sessuologia Clinica, 20, 5–23. Antonelli, P., Stefanile, C., & Dettore, D. (2010). Behavioural and cognitive aspects of Italian male same-sex couples: A qualitative research. Psicoterapia Cognitiva e Comportamentale, 16, 277. Balderrama-Durbin, C., Snyder, D. K., & Semmar, Y. (2011). Assessing Arabic couples: An evidence-based approach. Family Science, 2, 24–33. Barbagli, M., & Colombo, A. (2007). Omosessuali moderni. Gay e lesbiche in Italia [Modern homosexuals. Gay men and lesbians in Italy]. Bologna: Il Mulino. Bentler, P. M. (1990). Comparative fit indices in structural models. Psychological Bulletin, 107, 238–246. Bentler, P. M., & Bonett, D. G. (1980). Significance tests and goodness of fit in the analysis of covariance structure. Psychological Bulletin, 88, 588–606. Blumstein, P., & Schwartz, P. (1983). American couples: Money, work, sex. New York: William Marrow. Bollen, K. A., & Long, J. S. (Eds.) (1993). Testing structural equation models. Newbury Park, CA: Sage. Bradbury, T. N., Fincham, F. D., & Beach, S. R. H. (2000). Research on the nature and determinants of marital satisfaction: A decade review. Journal of Marriage and the Family, 62, 964–980. Elia, I. R., Antonelli, P., & Dettore, D. (2013). Il parenting nella maternit a lesbica: una ricerca italiana [Parenting among lesbian mothers: An Italian study]. In D. Dettore & A. Parretta (Eds.), Crescere nelle famiglie omosessuali. Un approccio psicologico [Growing up in homosexual families. A psychological approach] (pp. 135–146). Roma: Carocci editore. Gasbarrini, M. F., Snyder, D. K., Willson, V., & Newman, D. (2010). Adaptation of the Marital Satisfaction Inventory – Revised (MSI-R) in Germany, Spain, and Korea: An empirical analysis of structural invariance. In D. K. Snyder & C. Balderrama-Durbin (Eds.), Cross-national approaches to evidence-based couple assessment. Symposium presented at the meeting of the World Congress of Behavioral and Cognitive Therapies, Boston, MA. Gotta, G., Green, R. J., Rothblum, E., Solomon, S., Balsam, K., & Schwartz, P. (2011). Heterosexual, lesbian, and gay male relationships: A comparison of couples in 1975 and 2000. Family Process, 50, 353–376. Gottman, J. M., & Levenson, R. W. (1992). Marital processes predictive of later dissolution: Behavior, physiology, and health. Journal of Personality and Social Psychology, 63, 221–233. Gottman, J. M., Levenson, R. W., Gross, J., Frederickson, B. L., McCoy, K., Rosenthal, L. et al. (2003a). Correlates of gay and lesbian couples’ relationship satisfaction and relationship dissolution. Journal of Homosexuality, 45, 23–43. Gottman, J. M., Levenson, R. W., Swanson, C., Swanson, K., Tyson, R., & Yoshimoto, D. (2003b). Observing gay, lesbian and heterosexual couples’ relationships: Mathematical modeling of conflict interaction. Journal of Homosexuality, 45, 65–91. Graglia, M. (2009). Psicoterapia e omosessualit a [Psychotherapy and homosexuality]. Roma: Carocci editore. Green, R. J., & Mitchell, V. (2008). Gay and lesbian couples in therapy: Minority stress, relational ambiguity, and families of choice. In A. S. Gurman (Ed.), Clinical handbook of couple therapy (4th ed., pp. 662–680). New York: Guilford Press. Hu, L., & Bentler, P. M. (1998). Fit indices in covariance structure modeling: Sensitivity to underparameterized model misspecification. Psychological Methods, 3, 424–453. Istituto nazionale di statistica. (2012). Anno 2011. La popolazione omosessuale nella societ a italiana. Roma: Statistiche Report. [National Institute of Statistics. (2012). Year 2011. The homosexual population in Italian society. Rome: Statistics Report.] Julien, D., Chartrand, E., Simard, M., Bouthillier, D., & Begin, J. (2003). Conflict, social support, and relationship quality: An observational study of heterosexual, gay male, and lesbian couples’ communication. Journal of Family Psychology, 17, 419–428. Kiecolt-Glaser, J. K., & Newton, T. L. (2001). Marriage and health: His and hers. Psychological Bulletin, 127, 472–503. Kurdek, L. A. (1998). Relationship outcomes and their predictors: Longitudinal evidence from heterosexual married, gay cohabiting, and lesbian cohabiting couples. Journal of Marriage and Family, 60, 553–568. Kurdek, L. A. (2005). What do we know about gay and lesbian couples? Current Directions in Psychological Science, 14, 251–254. Means-Christensen, A. J., Snyder, D. K., & Negy, C. (2003). Assessing nontraditional couples: Validity of the Marital Satisfaction Inventory-Revised (MSI-R) with gay, lesbian, and cohabiting heterosexual couples. Journal of Marital and Family Therapy, 29, 69–83.

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Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129, 674–697. Newcomb, M. E., & Mustanski, B. (2010). Internalized homophobia and internalizing mental health problems: A meta-analytic review. Clinical Psychology Review, 30, 1019–1029. Peplau, L. A., & Cochran, S. D. (1981). Value orientations in the intimate relationships of gay men. Journal of Homosexuality, 6, 1–19. Peplau, L. A., & Fingerhut, A. W. (2007). The close relationships of lesbians and gay men. Annual Review of Psychology, 58, 405–424. Peplau, L. A., Fingerhut, A., & Beals, K. P. (2004). Sexuality in the relationships of lesbians and gay men. In J. Harvey, A. Wenzel, & S. Sprecher (Eds.), The handbook of sexuality in close relationships (pp. 349–369). Mahwah, NJ: Erlbaum. Platero, R. (2007). Love and the state: Gay marriage in Spain. Feminist Legal Studies, 15, 329–340. Riggle, E. D. B., Rostosky, S. S., & Horne, S. G. (2010). Psychological distress, well-being, and legal recognition in same-sex couple relationships. Journal of Family Psychology, 24, 82–86. Simons, T., & O’Connell, M. (2003). Married-couple and unmarried partner households: 2000. Washington, DC: U.S. Census Bureau. Retrieved February 8, 2014, from http://www.census.gov/prod/2003pubs/censr-5.pdf Snyder, D. K. (1997). Manual for the marital satisfaction inventory–revised. Los Angeles, CA: Western Psychological Services. Snyder, D. K., Castellani, A. M., & Whisman, M. A. (2006). Current status and future directions in couple therapy. Annual Review of Psychology, 57, 317–344. Snyder, D. K., Cepeda-Benito, A., Abbott, B. V., Gleaves, D. H., Negy, C., Hahlweg, K. et al. (2004). Cross-cultural applications of the Marital Satisfaction Inventory-Revised (MSI-R). In M. E. Maruish (Ed.), Use of psychological testing for treatment planning and outcomes assessment (3rd ed., pp. 603–623). Mahwah, NJ: Erlbaum. Snyder, D. K., Heyman, R. E., & Haynes, S. N. (2008). Assessing couple distress. In J. Hunsley & E. Mash (Eds.), A guide to assessments that work (pp. 439–463). New York: Oxford University Press. Solomon, S. E., Rothblum, E. D., & Balsam, K. F. (2005). Money, housework, sex, and conflict: Same-sex couples in civil unions, those not in civil unions, and heterosexual married siblings. Sex Roles, 52, 561–575. Steiger, J. H. (1990). Structural model evaluation and modification: An interval estimation approach. Multivariate Behavioral Research, 25, 173–180. Umberson, D., Williams, K., Powers, D., Liu, H., & Needham, B. (2006). You make me sick: Marital quality and health over the life course. Journal of Health and Social Behavior, 47, 1–16. Whisman, M. A. (2006). Role of couples relationships in understanding and treating mental disorders. In S. R. H. Beach, M. Z. Wamboldt, N. J. Kaslow, R. E. Heyman, M. B. First, L. G. Underwood, & D. Reiss (Eds.), Relational processes and DSM-V: Neuroscience, assessment, prevention, and treatment (pp. 225–238). Washington, DC: American Psychiatric Publishing. Whisman, M. A. (2013). Relationship adjustment and the prevalence, incidence, and treatment of psychopathology. Journal of Social and Personal Relationships, 30, 163–170. Whisman, M. A., Snyder, D. K., & Beach, S. R. H. (2009). Screening for marital and relationship discord. Journal of Family Psychology, 23, 247–254.

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