Abstract
Insecure romantic attachment style has been associated with greater substance use and higher risk sexual behavior, but the temporal nature of these associations is not well understood. This study examined whether having a more insecure attachment style was associated with greater engagement in higher risk sexual behavior over time and, if so, whether this was mediated by more frequent alcohol use. We used three annual waves of survey data from a diverse California cohort (N = 2,371) who were assessed from ages 19 to 21-22. Separate cross-lagged models examined temporal associations of insecure romantic attachment style (anxious, avoidant), past month alcohol use frequency, and sexual behavior (number of sex partners, condomless sex with casual and steady partners). Attachment anxiety was not directly associated with sexual behavior. Rather, a consistent pattern across waves showed that greater attachment anxiety was associated with more frequent alcohol use at the next wave, which, in turn, was associated with having more sex partners and condomless sex with casual and steady partners one year later. In contrast, greater attachment avoidance was directly associated with having fewer sex partners, and its associations with condomless sex differed across partner type and assessment waves. Attachment avoidance was unrelated to alcohol use frequency. Results indicated that both anxious and avoidant attachment styles were associated with higher risk sexual behavior, but in different ways and through different mechanisms. Future research may want to examine whether the effectiveness of sexual risk reduction programs for young people is enhanced by discussing attachment style and tailoring the curriculum accordingly.
Keywords: attachment style, alcohol, number of partners, unprotected sex, emerging adults
INTRODUCTION
During the past three decades, there has been a proliferation of studies describing ways in which adult attachment style is relevant to satisfaction and conflict within romantic relationships (Feeney & Fitzgerald, 2019; Mikulincer & Shaver, 2016). Adult attachment theory proposes that the emotional bond that adults develop with their primary attachment figure (typically a romantic partner) mirrors in some key respects the emotional bond they had as an infant with their primary caregiver due to the same attachment behavioral system underlying both types of relationships (Hazan & Shaver, 1987). An insecure attachment style is typically conceptualized in terms of two separate continuous underlying dimensions, attachment anxiety and attachment avoidance (Fraley et al., 2015). According to adult attachment theory, anxiety reflects the extent to which individuals worry about being underappreciated or abandoned in their relationships, whereas avoidance reflects the extent to which individuals are uncomfortable with closeness and emotional intimacy in their relationships (Simpson & Rholes, 2017). Behaviorally, these underlying concerns may manifest as highly anxious adults clinging to others as they strive for increasing emotional closeness and reassurance that the other person will be there for them in their time of need, and highly avoidant adults pulling away from others as they strive for independence and control in their relationships. Because anxiety and avoidance are separate dimensions of attachment, being low on one dimension does not necessarily imply being high on the other.
Attachment Style and Substance Use
In recent years, there has been an increasing focus on understanding the extent to which an insecure attachment style may contribute to behavioral health problems, such as substance use (Simpson & Rholes, 2017). Greater attachment anxiety and avoidance may both be risk factors for future substance use to the extent, for example, that more insecurely attached adults experience greater distress in their close relationships compared to those who are less insecurely attached (Feeney & Fitzgerald, 2019). However, it is also possible that engaging in more frequent substance use may lead to more insecure attachment over time, such as a desire to distance from close relationships due to one’s drinking or drug use. A recent meta-analysis by addressed these possibilities by focusing specifically on longitudinal studies of attachment security and substance use, examining 665 effect sizes drawn from 34 samples (total N = 56,721) (Fairbairn et al., 2018). Inclusion of studies was not limited to those examining adult attachment style nor to a particular attachment figure. Prospective correlations indicated that both attachment avoidance and attachment anxiety at an initial timepoint were associated with more substance use at a later time point, although the associations tended to be stronger for avoidance. These effects were found across all types of substances (alcohol, tobacco, cannabis, other substances). Further, an analysis of cross-lagged associations indicated that the pathway from earlier attachment to later substance use was significant, suggesting that both avoidant and anxious attachment styles may indeed be vulnerability factors for substance use. Although there was little evidence for a reverse effect (i.e., substance use being associated with attachment style at a later time point), further examination of cross-lagged effects is warranted given the limited longitudinal work in this area.
Attachment Style and Higher Risk Sexual Behavior
In addition to substance use, there has also been interest in understanding associations of adult attachment style with higher risk sexual behavior (Simpson & Rholes, 2017). For example, highly anxious individuals, due to their concerns about being abandoned by their partner, may engage in condomless sex as a way to increase relationship intimacy or because they want to avoid potential conflict with a partner by negotiating for safer sex. Highly avoidant individuals may have more sexual partnerships due to their need to avoid closeness and emotional intimacy in their relationships. A recent meta-analysis of 16 studies (42 effect sizes; total N = 7,233) examined associations of adult attachment styles with two widely studied higher risk sexual behaviors: having multiple sex partners and engaging in condomless sex (Kim & Miller, 2020). Results indicated that attachment anxiety had a small positive association with having more sexual partners and condomless sex, whereas attachment avoidance had a small positive association with having more sexual partners. To date, the vast majority of studies in this area have been cross-sectional; therefore, little is known about potential bidirectional associations of attachment style and sexual behavior. Further, about half of the existing studies focus on specific at-risk populations such as HIV-positive patients, sexual minority men, pregnant women, inner city youth, and youth transitioning out of foster care (Kim & Miller, 2020). Longitudinal research is needed to better understand the potential role that romantic attachment style may play in contributing to higher risk sexual behavior over time (and vice versa) in general population samples of young people.
Substance Use and Sexual Decision-Making
Several systematic reviews of the experimental literature have found that substance use – in particular, alcohol use – is associated with sexual decision-making, such as the intention to engage in condomless sex (Berry, & Johnson, 2018; Rehm et al., 2012; Scott-Sheldon et al., 2010). Further, although the evidence is mixed, event-specific studies have found that young people are more likely to engage in condomless sex with a casual partner when they have been drinking, although this is not necessarily the case for events involving a steady partner (Brown & Vanable, 2007; Kiene et al., 2009; LaBrie et al., 2005). Together, these studies suggest that substance use may mediate associations between attachment style and sexual behavior. In other words, attachment anxiety and avoidance may be associated with more frequent substance use over time which, in turn, increases the likelihood of engaging in higher risk sexual behavior. To the best of our knowledge, only one study has examined associations between attachment style, substance use, and sexual behavior: a cross-sectional analysis of survey data from 1,553 adolescents and young adults in Quebec (Lemelin et al., 2014). Substance use was considered a latent variable composed of three variables [frequency of using alcohol, “soft drugs” (e.g., cannabis), and “hard drugs” (e.g., cocaine)] and risky sexual behavior was considered a latent factor composed of two variables (age at first consenting sexual intercourse, number of sexual partners to date). Using structural equation modelling, results indicated that attachment avoidance was directly associated with higher risk sexual behaviors, and this association appeared to be mediated by substance use in the case of attachment anxiety. While suggestive, longitudinal analyses are needed to draw more definitive conclusions about the potential mediating role of substance use in associations between insecure attachment style and sexual behavior among emerging adults.
The Present Study
This study extends existing literature on insecure attachment style, substance use, and higher risk sexual behavior by examining their temporal associations over a 3-year period in a diverse sample of emerging adults between the ages of 18-25. Emerging adulthood is a distinct developmental period between adolescence and full-fledged adulthood that is characterized by instability, transition, and self-exploration (Arnett, 2014). Rates of substance use (Schulenberg et al., 2019) and sexually transmitted infections (Centers for Disease Control and Prevention, 2019) reach their peak during emerging adulthood, making it an important period during which to examine their associations with attachment style. In this study we focus specifically on alcohol use as it is the most prevalent type of substance use among emerging adults (Schulenberg et al., 2019), and as indicated earlier, has been associated with sexual decision making across a number of studies (Rehm et al., 2012; Scott-Sheldon et al., 2010). Based on existing cross-sectional literature, we hypothesized that higher attachment anxiety would be associated with more sex partners and greater engagement in condomless sex, whereas the associations of attachment avoidance with sexual behaviors were expected to differ by type of behavior (e.g., greater avoidance would be associated with more sex partners, but not with condom use). Further, based on findings from Lemelin et al. (2014), we expected that these associations between insecure attachment and sexual risk behavior would be mediated by alcohol use in the case of anxious attachment, but not avoidant attachment. Finally, we use cross-lagged models to explore whether engagement in substance use and higher risk sexual behavior was associated with changes in attachment style over time.
METHOD
Participants and Procedures
Participants were from two cohorts of 6th and 7th grade students enrolled in 2008 (Wave 1: mean age 11.5; n = 6,509) and subsequently followed through 2019 (Wave 11: mean age 21.6; n = 2,496). Participants were recruited from 16 middle schools across three school districts in Southern California, which were selected to obtain a diverse sample, as part of an evaluation of the voluntary after-school substance use prevention program called CHOICE (D'Amico et al. 2012a). CHOICE is a group-based program that consists of five distinct 30-minute sessions that are delivered using a Motivational Interviewing (MI) approach (Miller & Rollnick, 2012). Rates of lifetime and past month substance use in the sample have been comparable to national samples (D’Amico et al., 2012b). The CHOICE program, conducted over 10 years ago, showed effects on students’ alcohol use one year after the program; however, intervention effects were not observed beyond one year, and intervention status at Wave 1 has been unrelated to substance use or retention across study waves. Participants completed Waves 1-5 (Wave 1: Fall 2008; Wave 2: Spring 2009; Wave 3: Fall 2009; Wave 4: Spring 2010; Wave 5: Spring 2011) through paper-pencil surveys during PE classes at schools, with follow-up rates ranging from 74-90% (excluding new youth that could have come in at a subsequent wave) during this time period. Following Wave 5, participants transitioned from these middle schools to over 200 high schools. At that point they were re-contacted and re-consented to complete annual web-based surveys, with 61% of the sample participating in Wave 6 (Spring 2013-Spring 2014). Participants who did not complete a particular wave of data collection remained eligible to complete all subsequent waves. That is, they did not “dropout” of the study once they missed a survey wave; rather, we fielded the full sample at every wave so that all participants had an opportunity to participate in each individual survey. Wave-to-wave retention rates between Waves 6-11 ranged from 80-92% (Waves 6-7: 80%; Waves 7-8: 91%; Waves 8-9: 89%; Waves 9-10: 90%; and Waves 10-11: 92%). The present study used data from 2,371 individuals who participated in Waves 9 through 11 when information on attachment style was available (see Table 1 for information on the demographics of the sample from Wave 9). Substance use at Wave 10 was not significantly associated with retention at Wave 11, similar to previous waves (D’Amico et al., 2018; Dunbar et al., 2018). However, retained participants at Wave 11 were slightly more likely to be female (94% vs. 91%) and tended to be slightly younger at Wave 10 (mean = 20.6 years vs. 20.9 years). We did not find a significant difference in retention from Wave 10 to Wave 11 by race/ethnicity. Participants were paid $50 for completing each web-based survey. All participants consented to the study and procedures were approved by the study’s Institutional Review Board.
Table 1.
Descriptives of main study variables
| Wave 9 Mean (SD) / % |
Wave 10 Mean (SD) / % |
Wave 11 Mean (SD) / % |
|
|---|---|---|---|
| Age | 19.37 (0.75) | ||
| Male | 45.3% | ||
| Heterosexual | 88.2% | ||
| In college | 83.3% | ||
| Race/ethnicity a | |||
| Hispanic | 45.2% | ||
| Non-Hispanic White | 23.7% | ||
| Non-Hispanic Black | 2.2% | ||
| Asian | 23% | ||
| Multi-ethnic/Other | 5.8% | ||
| Anxious attachment (range = 1-42) | 22.67 (6.88) | 22.95 (6.89) | 23.13 (6.83) |
| Avoidant attachment (range = 1-42) | 18.48 (6.63) | 17.88 (6.71) | 17.82 (6.77) |
| Alcohol frequency past 30 days | 2.29 (4.34) | 3.55 (5.22) | 4.33 (5.83) |
| Number of sex partners (0-100) | 1.28 (5.49) | 1.28 (5.10) | 1.50 (5.38) |
| % condomless sex with casual partner (0-100) | 7.65 (25.25) | 7.95 (25.60) | 10.17 (28.69) |
| % condomless sex with steady partner (0-100) | 22.72 (39.98) | 28.33 (43.27) | 32.04 (45.02) |
Note. a Race/ethnicity was assessed at each of Waves 1-7 and we used the most recent data available to categorize participants.
Measures
Background covariates.
Cross-lagged models controlled for demographic characteristics at Wave 9 that may be associated with alcohol use and/or sexual behavior: age (in years), sex assigned at birth (female vs. male), sexual orientation (heterosexual, straight vs. lesbian, gay, bisexual, questioning, or asexual), and whether participants were currently enrolled in college. These analyses also controlled for race/ethnicity, which was assessed at each of Waves 1-7. We used the most recent data available to categorize participants as: non-Hispanic white (reference), non-Hispanic black, Hispanic, Asian, Multi-ethnic, and Other. In addition, cross-lagged models controlled for whether participants received the CHOICE intervention (yes/no).
Insecure Attachment Style (Waves 9, 10, 11).
We used the short form of the Experiences in Close Relationship Scale (Wei et al., 2007), which has two factors (6 items each): Anxiety (sample item: I need a lot of reassurance that I am loved by my partner; α = .77 at Wave 9) and Avoidance (sample item: I try to avoid getting too close to my partner; α = .74 at Wave 9). Instructions asked individuals to indicate how they generally experience romantic relationships, not just what is happening in a current relationship, by rating how much they agree/disagree with each of 12 statements (1 = strongly disagree to 7 = strongly agree). Items for each scale were reverse scored, as appropriate, and summed. Correlations between the two attachment types, both within- and across-waves, ranged from r = .074 to r = .277.
Alcohol Use (Waves 9, 10, 11).
At Waves 9 and 10, number of days of alcohol use in the past month was rated on a 7-point scale (0, 1, 2, 3-5, 6-9, 10-19, and 20-30 days). We recoded these items to be pseudo-continuous by using the mid-point of each response option (range: 0 to 25 days). At Wave 11, number of days of alcohol use in the past month was rated on a continuous scale from 0-30 days.
Sexual Behaviors (Waves 9, 10, 11).
Three separate behaviors were examined. To assess number of partners, participants were asked the number of people with whom they had vaginal, anal or oral sex in the past 3 months. Unprotected vagina or anal sex was assessed separately for steady partners (defined as “like a boyfriend/girlfriend”) and casual partner (defined as “like once-in-a-while, ‘in the moment,’ or maybe ‘just for fun.’”). Participants were first asked how many times they had vaginal or anal sex with each type of partner in the past 3 months, and then asked how many of those times they used a condom. From this information we calculated the percentage of condomless sexual events with steady partners and with casual partners in the past 3 months. Those who reported not having vaginal or anal sex with a particular type of partner in the past 3 months were coded as 0. Note that we did not assess unprotected oral sex because using protection during oral sex is quite uncommon among young adults (e.g., Holway & Hernandez, 2018). Correlations between the measures of sexual behavior, both within- and across-waves, never exceeded r = .225.
Analyses
Auto-regressive cross lagged (ARCL) models were estimated using three waves of survey data (N = 2,371) to test for temporal associations among attachment style, frequency of past month alcohol use, and sexual behavior (see Figure 1). Separate ARCL models were estimated for each combination of attachment style (anxious, avoidant) and higher risk sexual behavior (number of sex partners, condomless sex with casual partner, condomless sex with steady partner). In total, six ARCL models were estimated and evaluated for fit using conventional model fit criteria such as Root Mean Square Error of Approximation (RMSEA ≤ .08; MacCallum et al., 1996), Comparative Fit Index (CFI ≥ 0.95; Hu & Bentler, 1999), and Standardized Root Mean Residual (SRMR ≤ .08; Hu & Bentler, 1999). Equality constraints were imposed within each model to test whether the magnitudes of associations were stable across timepoints. Constraints were tested using the Wald test. A non-significant test indicated that parameters constrained to be equal did not differ statistically. All models were estimated in Mplus v8.1 (Muthen & Muthen, 2012-2018) and controlled for the background covariates listed above.
Figure 1.
Conceptual model of associations between attachment style, alcohol use, and sexual behavior
RESULTS
Anxious Attachment
We hypothesized that higher attachment anxiety would be associated with more sex partners and greater engagement in condomless sex; further, we expected that these associations would be mediated by alcohol use. Model coefficients and fit for anxious attachment ARCL models are presented in Table 2. As expected, having a more anxious attachment style at Wave 9 was associated with more frequent drinking at Wave 10 (β = 0.03 (CI: 0.002, 0.06), p =.038); in turn, more frequent drinking at Wave 10 was associated with more sex partners (β = 0.06 (CI: 0.03, 0.09), p < .001) and more condomless sex with both casual partners (β = 0.08 (CI: 0.04, 0.12), p < .001) and steady partners (β = 0.12 (CI: 0.08, 0.16), p < .001) at Wave 11. Similarly, having a more anxious attachment style at Wave 10 was associated with more frequent drinking at Wave 11 (β = 0.03 (CI: 0.002, 0.06), p = .034). Anxious attachment style was never directly associated with sexual behavior; rather, alcohol use mediated this association. Specifically, frequency of alcohol use at Wave 10 mediated the relationship from anxious attachment at Wave 9 to number of sex partners (β =.002 (CI: 0.0001, 0.003), p = .05), condomless sex with casual partners (β = 0.002, (CI: 0.0001, 0.01), p = .02), and condomless sex with steady partners (β =0.004 (CI: 0.0001, 0.01), p = .04) at Wave 11. There was little evidence of bidirectional associations with anxious attachment; that is, engagement in higher risk sexual behavior (or more frequent alcohol use) was not associated with emerging adults having a more anxious attachment style one year later.
Table 2.
Standardized coefficients from anxious attachment ARCL models
| Wave 10 |
Wave 11 |
|||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Anxious | Alcohol | Partners | Casual | Steady | Anxious | Alcohol | Partners | Casual | Steady | |
| Partners | ||||||||||
| Wave 9 | ||||||||||
| Anxious | 0.382a | 0.029c | 0.004 | |||||||
| Alcohol | −0.005 | 0.507a | 0.056a | |||||||
| Partners | −0.022 | −0.010 | 0.138a | |||||||
| Wave 10 | ||||||||||
| Anxious | 0.469a | 0.026c | 0.004 | |||||||
| Alcohol | −0.006 | 0.543a | 0.064a | |||||||
| Partners | −0.021 | −0.008 | 0.332a | |||||||
| Casual | ||||||||||
| Wave 9 | ||||||||||
| Anxious | 0.383a | 0.029c | 0.015 | |||||||
| Alcohol | −0.005 | 0.501a | 0.132a | |||||||
| Casual | 0.028 | 0.036a | 0.112a | |||||||
| Wave 10 | ||||||||||
| Anxious | 0.469a | 0.026c | 0.023 | |||||||
| Alcohol | −0.007 | 0.536a | 0.078a | |||||||
| Casual | −0.038 | 0.056a | 0.154a | |||||||
| Steady | ||||||||||
| Wave 9 | ||||||||||
| Anxious | 0.383a | 0.030c | 0.016 | |||||||
| Alcohol | −0.008 | 0.499a | 0.093a | |||||||
| Steady | 0.015 | 0.068a | 0.237a | |||||||
| Wave 10 | ||||||||||
| Anxious | 0.469a | 0.027c | 0.009 | |||||||
| Alcohol | −0.010 | 0.539a | 0.121a | |||||||
| Steady | 0.009 | 0.038a | 0.087a | |||||||
Notes. a p < .001; b p < .01; c p < .05. Anxious = anxious attachment. Alcohol = alcohol use frequency. Partners = number of sex partners.
Casual = condomless sex with casual partner. Steady = condomless sex with steady partner.
Number of sex partner: ꭓ2 = 352.686, RMSEA = 0.039, CFI = 0.908, SRMR = .031
Condomless sex with steady partners: ꭓ2 = 836.674, RMSEA = 0.066, CFI = 0.779, SRMR = 0.052
Condomless sex with casual partner: ꭓ2 = 444.244, RMSEA = 0.048, CFI = 0.872, SRMR = 0.037
In terms of associations between alcohol use and sex behavior, we found that more frequent alcohol use at Waves 9 and 10 were both associated with a greater number of sex partners at the next wave, but numbers of sex partners at Waves 9 and 10 were not prospectively associated with subsequent alcohol use. However, a reciprocal association was found between alcohol use and condomless sex: more frequent alcohol use at Wave 9 was associated with more condomless sex with casual partners (β = 0.13 (CI: 0.09, 0.18), p < .001) and steady partners (β = 0.09 (CI: 0.05, 0.13), p < .001) at Wave 10, and greater condomless sex with casual partners (β = 0.04 (CI: 0.02, 0.06), p < .001) and steady partners (β = 0.07 (CI: 0.04, 0.10), p < .001) at Wave 9 was associated with more frequent alcohol use at Wave 10. The same pattern was found between Wave 10 and Wave 11.
Avoidant Attachment
We hypothesized that associations of attachment avoidance with sexual behaviors would differ by type of behavior (e.g., greater avoidance would be associated with more sex partners, but not with condom use). Further, we did not expect that the associations between attachment avoidance and sexual behavior would be mediated by alcohol use. Model coefficients and fit for avoidant attachment ARCL models are presented in Table 3. We did not find significant associations between initial avoidant attachment style and subsequent alcohol use, nor associations between initial alcohol use and subsequent avoidant attachment style. However, in contrast to results for anxious attachment, there was a direct association between avoidance attachment and sexual behavior, with more avoidant attachment at Wave 9 being associated with fewer sex partners (β = −0.04 (CI: −0.08, 0.00), p = .049) and less engagement in condomless sex with casual partners (β = −0.11 (CI: −0.15, −0.07), p < .001), but more condomless sex with steady partners (β = 0.14 (CI: 0.10, 0.18), p < .001) at Wave 10. Interestingly, this pattern reverses from Wave 10 to 11 in the case of condomless sex such that more avoidant attachment at Wave 10 was associated with greater engagement in condomless sex with casual partners (β = 0.08 (CI:0.04, 0.13), p < .001), but less condomless sex with steady partners (β = −0.26 (CI: −0.30, −0.22), p < .001) at Wave 11. There was not a significant association between avoidance at Wave 10 and number of sex partners at Wave 11. There were no significant longitudinal associations between number of sex partners and avoidant attachment. However, greater engagement in condomless sex with casual partners at Wave 9 was associated with more avoidant attachment (β = 0.10 (CI: 0.06, 0.14), p < .001) at Wave 10, whereas greater engagement in condomless sex with casual partners at Wave 10 was associated with less avoidant attachment (β = −0.16 (CI: −0.19, −0.12), p < .001) at Wave 11. In the case of steady partners, greater engagement in condomless sex at Wave 9 was associated with less avoidant attachment (β = −0.06 (CI: −0.10, −0.02), p = .006) at Wave 10, with no association found between Wave 10 and Wave 11.
Table 3.
Standardized coefficients from avoidant attachment ARCL models
| Wave 10 |
Wave 11 |
|||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Avoidant | Alcohol | Partners | Casual | Steady | Avoidant | Alcohol | Partners | Casual | Steady | |
| Partners | ||||||||||
| Wave 9 | ||||||||||
| Avoidant | 0.483a | 0.013 | −0.042c | |||||||
| Alcohol | −0.020 | 0.507a | 0.056a | |||||||
| Partners | 0.007 | −0.011 | 0.140a | |||||||
| Wave 10 | ||||||||||
| Avoidant | 0.596a | 0.011 | 0.019 | |||||||
| Alcohol | −0.024 | 0.544a | 0.064a | |||||||
| Partners | 0.007 | −0.009 | 0.332a | |||||||
| Casual | ||||||||||
| Wave 9 | ||||||||||
| Avoidant | 0.480a | 0.017 | −0.111a | |||||||
| Alcohol | −0.014 | 0.501a | 0.133a | |||||||
| Casual | 0101a | 0.037a | 0.116a | |||||||
| Wave 10 | ||||||||||
| Avoidant | 0.566a | 0.016 | 0.082a | |||||||
| Alcohol | −0.016 | 0.537a | 0.075b | |||||||
| Casual | −0.058a | 0.058a | 0.169a | |||||||
| Steady | ||||||||||
| Wave 9 | ||||||||||
| Avoidant | 0.478a | 0.014 | 0.532a | |||||||
| Alcohol | −0.025 | 0.603a | 0.524a | |||||||
| Steady | −0.009b | 0.009a | 0.163a | |||||||
| Wave 10 | ||||||||||
| Avoidant | 0.599a | 0.014 | −1.670a | |||||||
| Alcohol | −0.025 | 0.603a | 0.967a | |||||||
| Steady | 0.003 | 0.009a | 0.202a | |||||||
Notes. a p < .001; b p < .01; c p < .05. Anxious = anxious attachment. Alcohol = alcohol use frequency. Partners = number of sex partners.
Casual = condomless sex with casual partner. Steady = condomless sex with steady partner.
Number of sex partner: ꭓ2 = 334.016, RMSEA = 0.038, CFI = 0.927, SRMR = 0.028
Unprotected sex with casual partner: ꭓ2 = 414.306, RMSEA = 0.046; CFI = 0.906, SRMR = 0.03
Unprotected sex with steady partners: ꭓ2 = 751.095, RMSEA = 0.065, CFI = 0.838, SRMR = 0.0
As would be expected, the same patterns of associations between alcohol use and higher risk sexual behavior were found as in the anxious attachment models. More frequent alcohol use at Waves 9 and 10 were both associated with greater number of sex partners at the next wave, but not vice versa. However, a reciprocal association was found between alcohol use and condomless sex: those who engaged in more frequent alcohol use at Wave 9 tended to report more condomless sex with casual partners (β = 0.13 (CI: 0.09, 0.18), p < .001) and steady partners (β = 0.09 (CI: 0.05, 0.13), p < .001) at Wave 10, and those who reported more condomless sex with casual partners (β = 0.04 (CI: 0.02, 0.06), p < .001) and steady partners (β = 0.07 (CI: 0.04, 0.10), p < .001) at Wave 9 tended to report more frequent alcohol use at Wave 10. The same pattern was found between Wave 10 and Wave 11.
DISCUSSION
This three-year longitudinal study extends the existing literature on insecure attachment style and higher risk sexual behavior by examining their temporal associations over time, including the potential mediating role of alcohol use, in a racially/ethnically diverse sample of emerging adults. Based on results from prior cross-sectional studies (e.g., Lemelin et al., 2014), we hypothesized that higher attachment anxiety would be associated with more frequent alcohol use one year later, which in turn would be associated with higher risk sexual behavior at the next annual assessment. We found support for this mediation model across all three outcomes: multiple partners, condomless sex with casual partners, and condomless sex with steady partners. There is a sizable literature showing that individuals with attachment anxiety have deficits in emotional regulation (Mikulincer & Shaver, 2019), and thus may be more inclined to use alcohol as an external means of regulating their emotions. Their more frequent alcohol use, in turn, may put them at heightened risk for multiple partnerships and condomless sex. This raises the possibility that sexual risk reduction programs for emerging adults with attachment anxiety may be particularly effective if they include a focus on how alcohol use is related to higher risk sexual behavior and offer healthier alternatives to regulating negative emotions such as exercise or meditation. Further, given that attachment style is relatively stable from childhood to young adulthood (Waters et al., 2000), assessing attachment style in early adolescence may identify young people at elevated risk for later substance use and related risk behaviors and thus be a useful tool for early intervention.
As expected, associations with attachment avoidance were more complex than those for attachment anxiety, differing across waves, by type of sexual behavior, and in the role of alcohol use. Unlike findings for attachment anxiety, our results suggest that attachment avoidance is directly associated with sexual behavior, rather than this association being mediated by alcohol use. In terms of sexual partnerships, greater attachment avoidance was associated with having fewer partners. However, this was limited to the period from age 19 to 20, raising the possibility that it may be specific to the transition out of high school and (for most) into college rather than reflective of a more general pattern. Although a recent meta-analysis concluded that avoidance had a small positive association with number of sex partners (Kim & Miller, 2020), it was mostly based on studies that were cross-sectional and focused on at-risk populations. These methodological differences with the current study may at least partially account for disparate findings, but additional longitudinal research with general population samples of emerging adults are needed to determine whether our findings are robust.
In the case of condomless sex, the meta-analysis by Kim and Miller (2020) found no overall association between attachment avoidance and engagement in condomless sex. Our results suggest that this may be due to the association being more nuanced and dynamic, differing over time and by partner type. For example, we found that greater attachment avoidance at age 19 was associated with less use of condoms with steady partners and greater use of condoms with casual partners at age 20, but the opposite pattern was found from age 20 to 21-22 with greater condom use with steady partners and less use of condoms with casual partners. Given that stronger attachment avoidance is associated with more favorable attitudes towards uncommitted sexual relationships (Brennan & Shaver, 1995; Feeney et al., 1993), this pattern may reflect a tendency for avoidant young people, as they move from their teens to early 20s, to increasingly seek out casual (rather than steady) partners and have less concern about the possible consequences of unprotected sex. The complexity of the results for avoidant attachment highlights the need for more longitudinal and experimental research to better understand the conditions under which this type of insecure attachment may predispose young people to engage in higher risk sexual behavior.
Finally, it is important to note that more frequent alcohol use was not a significant risk factor for greater attachment anxiety or avoidance over time in the present study. This is consistent with meta-analytic results from prior cross-lagged analyses indicating that earlier attachment style is significantly associated with later substance use, but not the reverse (Fairbairn et al., 2018). However, as Fairbairn and colleagues (2018) have pointed out, this should not be taken as evidence that substance use does not have a detrimental effect on close relationship bonds. Rather, our results provide little evidence that more frequent drinking per se leads emerging adults to become more insecurely attached within their romantic relationships.
Results from this study should be considered in light of several study limitations. First, results are based on a predominantly California sample of emerging adults and thus may not generalize to other age groups or young people in other geographic locations. Second, the study would have been strengthened by examination of additional indicators of higher risk sexual behavior, such as concurrent partnerships or unprotected oral sex, as well as related outcomes such as unwanted pregnancy or being diagnosed with a STI. Third, it was outside the scope of this study to conduct multi-group auto-regressive cross lagged models to test for differences in the associations of attachment styles, alcohol use, and sexual behaviors by age, sex assigned at birth, sexual orientation, college status, and race/ethnicity (although analyses controlled for these demographic characteristics). Understanding how the associations examined in this study might differ across key sociodemographic subgroups is an important direction for future research.
Results from this study indicate that both anxious and avoidant attachment styles are associated with higher risk sexual behavior over time, but in different ways and through different mechanisms. This points to the importance of additional longitudinal research to understand how adult attachment style influences sexual behavior over time, including a focus on potential differences by sociodemographic characteristics. In particular, the complex associations of attachment avoidance with higher risk sexual behavior deserve more attention – both in terms of understanding differences across types of sexual behaviors and what factors might underlie these associations that can be targeted in intervention efforts. As more is learned about the connections between attachment style and higher risk sexual behavior, another important direction for future research is to examine whether the effectiveness of sexual risk reduction programs for young people is enhanced by discussing attachment style and tailoring the program curriculum accordingly.
Acknowledgements:
This research was supported by three grants from the National Institute on Alcohol Abuse and Alcoholism (R01AA016577, R01AA020883, R01AA025848; PI: D’Amico). The authors would like to thank Jennifer Parker for overseeing the web-based surveys.
Footnotes
Conflict of Interest. The authors declare that they have no conflicts of interest.
Ethical Approval. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed Consent. Informed consent was obtained from all individual participants included in the study.
Disclaimer. The content is solely the responsibility of the authors and does not represent the official views of any of the funding agencies.
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