Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2018 Jun 1.
Published in final edited form as: Psychol Sex Orientat Gend Divers. 2017 Jun;4(2):241–250. doi: 10.1037/sgd0000225

Eriksonian intimacy development, relationship satisfaction, and depression in gay male couples

Tyrel J Starks 1,2,3, Kendell M Doyle 1,3, Brett M Millar 2,3, Jeffrey T Parsons 1,2,3
PMCID: PMC5966044  NIHMSID: NIHMS907552  PMID: 29805985

Abstract

Research suggests connections or links between the mental health of both partners in a romantic relationship, as partners often report similar mental health problems, with implications for relationship functioning. The current study utilized the framework of interdependence theory to explore associations among intimacy development, as conceptualized by Erikson, relationship satisfaction, and depression in a sample of 128 same-sex male couples. In each couple, one partner was recruited first through active or passive outreach conducted online and in-person, and after completion of the online survey, was then invited to send his partner a link to the study. The 256 male respondents (mean age = 32.6 years) all reported a U.S. residence and had an average relationship length of five years. Utilizing the Actor-Partner Interdependence Model, analyses indicated that participants’ intimacy development directly predicted their own relationship satisfaction (B = 1.84, p< .01) as well as their partner’s relationship satisfaction (B = 1.61, p<.01). Similarly, both the actor (B = -0.04, p< .01) and partner (B = -0.04, p< .05) effects of relationship satisfaction on depression were significant. Consistent with the interdependent concept of joint control, three indirect pathways linked Eriksonian intimacy to depression through relationship satisfaction. These findings suggest that individual development may become linked to mental health through pathways involving dyadic functioning. This pattern implies highly inter-connected links between the intra-personal and inter-personal, which have implications for mental health intervention with gay men in relationships.

Keywords: dyadic, same-sex couples, romantic relationships, Erikson development, depression

INTRODUCTION

Research on the interpersonal functioning of gay male couples has expanded in recent years. The public health significance of this work has been highlighted by studies indicating that HIV transmission between main partners accounts for a substantial number (35-68%) of new infections in this population (Goodreau et al., 2012; Sullivan, Salazar, Buchbinder, & Sanchez, 2009). Subsequently, research has examined couples-relevant factors, such as sexual agreements, related to HIV infection risk (e.g., Grov, Starks, Rendina, & Parsons, 2014; Mitchell, Boyd, McCabe, & Stephenson, 2014; Parsons, Starks, Dubois, Grov, & Golub, 2013). While this work is critical for HIV prevention, the existing literature contains indications that primary relationships are potentially connected to individuals’ overall health, in particular mental health, in ways that have received considerably less attention.

Much like sexual health, research on heterosexual couples suggests that mental health outcomes for relationship partners are linked. This link is expressed partially in the similarity of partners’ reported mental health functioning. Partners are likely to have similar psychiatric diagnoses (Galbaud du Fort, Bland, Newman, & Boothroyd, 1998; Maes et al., 1998; McLeod, 1995; Van Orden et al., 2012) or suffer from similar psychiatric symptoms (Dubuis-Stadelmann, Fenton, Ferrero, & Preisig, 2001). Indeed, Kouros and Cummings’(2010) longitudinal study of married couples found that increases in the severity of husbands’ depressive symptoms predicted subsequent increases in the severity of wives’ symptoms over the course of three years. In addition, partners living with a depressed spouse are at increased risk for developing depression themselves (Benazon & Coyne, 2000; Teichman, Bar-El, Shor, & Elizur, 2003).

The mental health of relationship partners may be linked because mental health covaries with relationship functioning. Lower relationship satisfaction is associated with greater symptoms of depression in married heterosexual adults (Rehman, Evraire, Karimiha, & Goodnight, 2015; Whisman, 2001), heterosexual emerging adults (Whitton & Kuryluk, 2012), and gay and lesbian couples (Whitton & Kuryluk, 2014). Additionally, individuals’ self-reported levels of depression were associated with their own perceived marital satisfaction, as well as their partner’s marital satisfaction (e.g., Whisman, Uebelacker, & Weinstock, 2004).

Although research on mental health and relationship functioning has been dominated by a focus on heterosexual couples, a growing body of literature focusing on same-sex male couples is emerging. This work has primarily been conducted within the framework of Couples Interdependence Theory (CIT; Lewis, Gladstone, Schmal, & Darbes, 2006; Rusbult, Verette, Whitney, Slovik, & Lipkus, 1991; Whitton & Kuryluk, 2014). This dyad-level theory explains how interactions with a partner can influence the couple’s outcomes, relationship functioning, and individual-level well-being (Kelley & Thibaut, 1978; Rusbult & Van Lange, 2003). CIT gives substantial attention to the interdependence between partners, meaning the ability of each partner to affect the other’s outcomes. Interdependence is analyzed by considering three types of predictor–outcome relationships: (a) the association between each individual’s own actions and their own outcome (actor control); (b) the association between an individual’s own outcome and their partner’s actions (partner control); and (c) the coordination of partners’ joint actions on the individual’s behavior outcomes (joint control), in which the effects are shared by members of the couple (Kelley & Thibaut, 1978; Rusbult & Van Lange, 2003).

When one member of a couple engages in destructive behavior during times of joint control, the reaction of the reciprocating partner may exacerbate or mitigate negative outcomes. During these moments of conflict, the reciprocating partner has the opportunity to react based on either self-interest or, alternatively, on a transformed motivation that considers both partners’ interests, with an emphasis on longer term relationship goals, through the process of accommodation (Rusbult, Bissonnette, Arriaga, Cox, & Bradbury, 1998; Rusbult & Van Lange, 2003; Rusbult et al., 1991; Yovetich & Rusbult, 1994). The accommodation process promotes couple well-being (Rusbult, Yovetich, & Verette, 1996), predicts greater relationship satisfaction over time (Rusbult et al., 1998), and results in more positive outcomes after a relationship conflict (Finkel & Campbell, 2001; Rusbult & Van Lange, 2008; Rusbult et al., 1991). This is important given findings that conflict within romantic relationships can lead to the emergence of mental health problems, such as depression (Mackinnon et al., 2012; Whisman & Uebelacker, 2009).

This process of accommodation is partly facilitated by individual-level factors, such as greater satisfaction, commitment, or emotional investment in the relationship (Rusbult et al., 1991). Therefore, there is reason to believe that the functioning of couples may be directly linked to the development of each partner’s capacity for intimacy. While Erikson (1968), in his psychosocial theory of development, afforded substantial attention to the individual’s development of intimacy, and highlighted its salience particularly in late adolescence and emerging adulthood, it has been given relatively scant attention in the CIT literature. Findings indicate that accomplishment of the intimacy stage is associated with marital satisfaction (Erikson, 1963; Moss & Schwebel, 1993). Further, intimacy is associated with lower levels of depression (Finkbeiner, Epstein, & Falconier, 2013), and is more difficult to sustain within relationships when one or more partners is depressed (Basco, Prager, Pita, Tamir, & Stephens, 1992).

Although links have been observed among relationship satisfaction, Eriksonian intimacy, and mental health in heterosexual couples, no studies have tested the significance of such an indirect pathway in a context that also examines the interdependence of partner outcomes consistent with CIT. Furthermore, these links have not yet been examined in partnered gay and bisexual men. Accordingly, the goal of the current study was to examine the interdependence of Eriksonian intimacy, relationship satisfaction, and mental health within gay male couples by testing pathways within an Actor-Partner Interdependence Model (APIM) framework. The APIM examines the impact of predictive factors for an individual and their outcome as well as their partner’s outcome in addition to the shared variables within the dyad (Kenny, 1996; Kenny, Kashy, & Cook, 2006; Ledermann, Macho, & Kenny, 2011). By utilizing APIM, we can measure interdependence as defined in CIT within couples and determine whether behavioral outcomes are associated with the individual, their partner, or joint efforts (Cook & Kenny, 2005).

Consistent with existing literature, we hypothesized that participants’ level of Eriksonian intimacy would be positively associated with their own relationship satisfaction as well as that of their partner. We also hypothesized that participants’ level of Eriksonian intimacy would be negatively associated with their own depression scores as well as that of their partner. Finally, we anticipated that participants’ relationship satisfaction would be negatively associated with their own depression scores as well as that of their partner. Of note, these hypothesized associations were predictive, not causal in nature. We also examined whether participants’ Eriksonian intimacy scores might account for a significant amount of variance in depression scores (both their own and their partners) through indirect pathways involving actor and partner effects of relationship satisfaction. This examination of indirect effects was intended purely as an extension of predictive hypotheses and was not conceived as an examination of causal mechanisms.

METHODS

Participants

Eligible participants included gay male couples where both partners reported being biologically male, male-identified, and aged 18 or older. In total, the online survey was opened 682 times. Of these, 467 (68.5%) surveys were completed by unique individuals. These included a total of 339 index participants. Of these, 128 (37.8%) successfully recruited their partners. A detailed analysis of differences among index participants based upon willingness and ability to recruit their partner is reported elsewhere Starks, Millar, & Parsons (2015).

Procedure

Data were collected between December 2011 and February 2013, utilizing both online and in-person recruitment. Online recruitment activities included the distribution of study information via listservs and websites targeting the gay community across the United States. These materials were also sent to partnered gay men who had completed, or were ineligible for, other studies with our research center and had indicated an interest in future studies. Online recruitment materials described the study as being focused on gay couples and contained a direct link to the survey, as well as study contact information. In-person recruitment activities included attendance by study staff at community and social events frequented by gay men in the New York City area. Additionally, a small number of participants (n = 13) were recruited following participation in another research project that involved in-person assessment.

We utilized an “index case” approach to the recruitment of couples, by which index participants were given the option to refer their partners to the study by providing their partners’ contact email. When index participants chose to refer their partners, the survey generated an automatic email, which they could modify before sending if they wished. Participants were compensated both individually and as a couple. Any participant who completed the survey and included their mailing address received a free movie ticket. Couples in which both index and referred partners completed the survey were also entered into a raffle to receive an additional $100 compensation. The raffle prize was given to 1 in every 25 completed couples. All recruitment materials and procedures were approved by the institutional review board Hunter College of the City University of New York.

Measures

Demographics

Participants indicated their age, sexual identity, race and ethnicity, HIV serostatus (positive, negative, unknown), education level, and individual income level. Participants provided geographic information in the form of their zip code of residence, which was used to determine the region of the U.S. in which the participant resided. Participants also provided information related to the duration of relationship (in months). Where partners’ estimation of relationship length differed, responses were averaged. In order to reduce skew for relationship length, responses on this variable were Winsorized at the 95th percentile. In other words, 5% of couples (n = 12 individuals) reported a relationship length longer than 212 months. These participants were assigned values of 213, 214, 215, 216, 217 and 218 months to preserve the rank order of their responses. The resulting variable had M = 54.7 (SD = 59.5).

Similar to other studies (Parsons et al., 2013; Parsons, Starks, Gamarel, & Grov, 2012), relationship arrangement was assessed using a single item asking participants to report how they and their partners “handled sex outside of their relationship.” Participants who reported “neither of us has sex with others, we are monogamous,” or “I don’t have sex with others and I don’t know what my partner does” were classified as monogamous. Those who reported, “only I have sex with others,” “only he has sex with others,” “both of us have sex with others separately,” “we both have sex with others separately and together,” or “I have sex with others and I don’t know what my partner does” were classified as open. Those who reported “both of us have sex with others together” were classified as monogamish (Parsons et al., 2013).

In 106 couples, partners agreed on how they handle sex outside their relationship. Of these, 78 concurred they were monogamous, 8 concurred they were monogamish, and 20 concurred they were open. Among the 22 couples in which partners’ responses were discrepant, 15 couples involved one partner who reported a monogamous arrangement while the other reported an open arrangement. In five couples, one partner described the relationship as monogamish and the other described it as open. Consistent with previous research (Parsons et al., 2013), we coded these 20 couples as “discrepant.” Finally, in two couples, one partner reported a monogamous arrangement and the other reported a monogamish arrangement. Consistent with previous research (Parsons et al., 2013), we coded these couples as monogamish.

Eriksonian Intimacy Development

Development of capacity for intimacy as conceptualized within Erikson’s theory of psychosocial development was assessed using the 12-item Intimacy subscale of the Erikson Psychosocial Stage Inventory (EPSI) (Rosenthal, Gurney, & Moore, 1981). Participants indicated their level of agreement with a series of 12 statements (e.g., “I’m warm and friendly” and “I care deeply for others”) on a Likert-type scale from 1 (Strongly disagree) to 5 (Strongly agree), with higher total scores indicating greater development of intimacy. The EPSI measure has demonstrated strong reliability and validity in previous studies (Rosenthal et al., 1981; Sandor & Rosenthal, 1986) including studies which involved individuals in relationships (e.g., Christiansen & Palkovitz,1998; Leidy & Darling-Fisher, 1995). In this current study, the scale demonstrated strong reliability (Cronbach’s α = .82).

Relationship satisfaction

Relationship satisfaction was measured using the 7-item Relationship Assessment Scale (Hendrick, 1988). Responses were indicated on a 5-point Likert-type scale from 1 (Poorly) to 5 (Extremely well) on items such as “In general, how satisfied are you with your relationship?” and “How well does your partner meet your needs?”. Higher total scores indicate greater relationship satisfaction. The scale has been used in numerous previous studies (e.g., Cramer, 2000; Wester, Pionke, & Vogel, 2005) and, in the current study, displayed strong reliability (Cronbach’s α = .86).

Depression

Participants completed the depression subscale of the Brief Symptom Inventory (Derogatis & Melisaratos, 1983). Participants indicated how much they were distressed by each of six depressive symptoms (e.g., “Feeling no interest in things”) on a Likert-type scale from 1 (Not at all) to 5 (Extremely). Scores were averaged across items with higher scores indicating greater depressive symptomatology. The scale demonstrated strong reliability (Cronbach’s α = .91).

Analytic Approach

The similarity of partners’ demographic characteristics was evaluated using the intra-class correlation for normally distributed variables and κ for categorical variables. Both of these statistics vary between -1.0 and 1.0 with large absolute values indicating a greater proportion of the variable’s variance is accounted for by couple membership. Subsequent analyses were analyzed using the APIM framework (Kenny, et al., 2006). The APIM is a multi-level modeling approach. At Level I (the individual or partner level), the model distinguishes between actor and partner effects. Actor effects quantify the association between participants’ score on an outcome and their own score on a predictor variable. In contrast, partner effects quantify the association between participants’ scores on an outcome and their partners’ scores on a predictor. The model also incorporates couple-level variables such as relationship length and sexual arrangement, on which both members of the couple have identical responses, at Level II.

Using Mplusv7.3., we calculated a structural equation APIM in which depression was predicted by actor and partner effects associated with EPSI Intimacy scores and relationship satisfaction as well as age, HIV status, race and ethnicity, and income at Level I, and with sexual arrangement and relationship length at Level II. In this model, relationship satisfaction was also modeled as a Level I outcome predicted by actor and partner effects associated with EPSI Intimacy scores, age, race and ethnicity, and income. In response to the cross-sectional nature of the data, we calculated two additional equivalent models (Kline, 2015) which varied the configuration of Level I variables. Both of these models included the sample Level II predictors as our model of primary interest and all regressions of Level I endogenous variables included age, race and ethnicity, and income as covariates. In the first, relationship satisfaction as predicted by actor and partner effects of relationship satisfaction, which was in turn predicted by actor and partner effects of EPSI scores. In the second model, both depression and relationship satisfaction were regressed on the actor and partner effects of EPSI scores. Actor and partner depression and relationship satisfaction scores were permitted to correlate but no predictive association was specified.

The significance of indirect effects was assessed using a constraint approach. This approach compares the fit of two models. In one model, the product of the direct effects which comprise the indirect pathway being tested is constrained to be 0. The fit of this model is then compared to one in which the product of the constituent direct paths is allowed to vary freely using a χ2 test. A significant χ2 statistic resulting from this test indicates that the model constraint significantly reduces model fit and provides evidence that the indirect effect is significant. Of note, a constraint approach to testing indirect effects was utilized because bootstrapping approaches to indirect effect testing is not available in multi-level analyses (Muthen & Muthen, 2010).

RESULTS

Demographic information and descriptive data for the sample are reported in Table 1. Average age of participants in the sample was 32.6 years (SD = 10.6). The majority identified as White (67.2%) and had completed at least a four year college degree (71.9%). Approximately half of the sample (48.4%) reported an individual income of at least $40,000 annually. Couples had been together for an average of 58.1 (SD = 72.3; range 2 to 468) months, or approximately 4 years 10 months, prior to the application of the Winsorizing procedure described above. Where members of the same couple reported different relationship length, an average of their reports was used. With regard to geographic location, 215 (84%) participants reported living in the Northeastern United States (with 154 participants reporting a NYC address or regular visits to NYC), 10 (3.9%) in the Midwest, 16 (6.3%) in the South, and 13 (5.1%) in the West. Geographic data were not available for two participants.

Table 1.

Individual demographic characteristics and partner interdependence

n (%)
κ
Overall 256
Race and Ethnicity .20**
 White/European 172 (67.2)
 Black/African American 18 (7.0)
 Latino 34 (13.3)
 Other 32 (12.5)
HIV status .57**
 Positive 215 (84.0)
 Negative 41 (16.0)
Education
 Less than a 4 year degree 72 (28.1) .19*
 4 year degree or more 184 (71.9)
Annual Income
 Less than $40,000 132 (51.6) .47**
 $40,000 or more 124 (48.4)
M (SD) ICC
Age 32.6 (10.6) .72**
Relationship satisfaction 29.5 (4.4) .48**
Depression 0.76 (0.87) .25**
EPSI Intimacy 3.9 (0.6) .06
Open in a new tab
*

p ≤ .05

**

p ≤ .01

Descriptively, the average level of relationship satisfaction in this sample (M = 25.5, SD = 2.4) was comparable to a previous study of gay men in 2005 (M = 25.6, SD = 3.4) (Wester et al., 2005). The average depressions core in this sample (M = .76, SD = 0.87) corresponds to a T score of 65 when compared to norms for non-patient males (Derogatis, 1993). Examination of intraclass coefficient (ICC) and κ values indicated a general trend toward a modest degree of demographic similarity between partners within a relationship. Couple membership accounted for a significant amount of variance in age, race and ethnicity, income, education, and HIV status. Couple membership also accounted for a significant amount of variability in depression and relationship satisfaction. The ICC for EPSI Intimacy scores was non-significant, implying that partners within a couple were no more similar to one another than they were to other individuals in the sample outside of their relationship.

Structural associations among intimacy, relationship satisfaction, and depression

Results of the multi-level structural equation APIM, which models associations among intimacy, relationship satisfaction, and depression, are contained in Table 2. Associations among constructs of primary interest are depicted in Figure 1. With respect to relationship satisfaction, both the actor and partner effects of EPSI Intimacy scores were statistically significant. Men with higher intimacy scores tended to report higher relationship satisfaction scores. In addition, men whose partner had higher intimacy scores also tended to report higher relationship satisfaction. Furthermore, partner age (but not participant’s own age) was negatively associated with relationship satisfaction. Conversely, the actor effect of HIV status was statistically significant. HIV-positive men reported significantly lower relationship satisfaction scores than HIV-negative men. The partner effect of HIV status was not significant. Actor and partner effects of race and ethnicity, and income were non-significant.

Table 2.

APIM: Structural equation model coefficients

Relationship Satisfaction Depression
R2 = .20
R2 = .22
B 95% CI β B 95% CI β
Relationship Satisfaction
 Actor -- -- -- -0.04** (-0.06, -0.01) -.18
 Partner -- -- -- -0.04* (-0.07, -0.01) -.20
EPSI
 Actor 1.84** (1.08, 2.61) .24 -0.27** (-0.48, -0.07) -.19
 Partner 1.61** (0.76, 2.47) .21 -0.02 (-0.20, 0.16) -.01
Age
 Actor 0.05 (-0.003. 0.10) .12 -0.01 (-0.02, 0.01) -.07
 Partner -0.05* (-0.10, -0.004) -.13 0.00 (-0.02, 0.02) .00
Race (ref = non-white)
 Actor -0.09 (-1.35, 1.18) -.01 0.02 (-0.21, 0.25) .01
 Partner 0.40 (-0.83, 1.63) .04 0.06 (-0.17, 0.02) .03
HIV status
 Actor -2.00* (-3.66, -0.34) -.17 0.19 (-0.13, 0.52) .08
 Partner -1.18 (-2.65, 0.29) -.10 -0.17 (-0.47, 0.13) .08
Income
 Actor 0.80 (-0.22, 1.82) .09 -0.26* (-0.46, -0.06) -.16
 Partner 0.70 (-0.26, 1.65) .08 -0.12 (-0.36, 0.12) -.07
Relationship length -- -- -- 0.00 (-0.003, 0.002) -.14
Sexual agreement (ref = non-monogamy)
 Monogamish -- -- -- -0.07 (-0.45, 0.30) -.10
 Open -- -- -- 0.10 (-0.22, 0.43) .17
 Discrepant -- -- -- -0.08 (-0.36, 0.20) -.14
Open in a new tab
*

p ≤.05;

**

p ≤.01

Figure 1.

Figure 1

Open in a new tab

Primary model of interest: Relationship satisfaction as a mediator of the association between intimacy and depression

*p≤.05; **p≤.01

With respect to depression, there was a significant actor effect of EPSI Intimacy scores on depression. Higher levels of EPSI Intimacy were associated with lower reported depression scores. Meanwhile, the partner effect of EPSI Intimacy scores on depression was not statistically significant. In contrast, both the actor effect and partner effects of relationship satisfaction were statistically significant. Men with higher relationship satisfaction and those whose partners were more satisfied had lower depression scores. With respect to covariates, individual (but not partner) income was negatively associated with depression. The actor and partner effects of age, race and ethnicity, HIV status, relationship length, and sexual arrangement were not statistically significant.

Indirect effects of EPSI Intimacy scores on depression through relationship satisfaction

In addition to the direct/main effect of one’s own EPSI Intimacy score on one’s own depression, the pattern of main effects pointed to four possible indirect pathways linking EPSI Intimacy scores and depression. In the first pathway, participants’ EPSI Intimacy scores predicted their own relationship satisfaction scores. In turn, participants’ relationship satisfaction scores predicted their own depression scores. Constraining this pathway to be 0 resulted in a statistically significant decrease in model fit (Wald χ2(1) = 4.8; p = .03). In the second pathway, participants’ EPSI Intimacy scores predicted their own relationship satisfaction scores and subsequently, participants’ relationship satisfaction scores were associated with their partners’ depression scores. Constraining this pathway to be 0 resulted in a statistically significant decrease in model fit (Wald χ2(1) = 5.35; p = .02). In the third pathway, participants’ EPSI Intimacy scores predicted their partner’s relationship satisfaction scores, and in turn, men’s reported relationship satisfaction predicted their reported depression scores. Constraining this indirect pathway to be 0 did not significantly diminish model fit (Wald χ2(1) = 2.77; p = .10). Finally, in the fourth pathway, participants’ EPSI Intimacy scores predicted their partner’s relationship satisfaction scores, and in turn, their own depression scores were predicted by partners’ relationship satisfaction. Constraining this indirect pathway to be 0 significantly diminish model fit (Wald χ2(1) = 3.84; p = .05).

Post hoc test of alternative models

As Kline (2015) has argued, multiple models may account for observed associations among variables in cross-sectional data. In the absence of a research design which imposes temporal order on the assessment of constructs, researchers must rely upon theory when specifying the direction of effects in models where indirect effects are plausible and alternative equivalent specifications often exist. The model of primary interest thus far was viewed as most plausible based upon our review of the literature; however, we tested two alternative models which reversed the direction of some effects in order to illustrate the multiple ways in which the observed pattern of covariation observed in these data might be understood.

The first of these alternative models exchanged the position of depression and relationship satisfaction and thus considered the possibility that EPSI Intimacy scores may be associated with relationship satisfaction indirectly through depression. Results for this model are depicted in Figure 2. Findings here are highly consistent with the model of primary interest. The direct actor and partner effects of EPSI Intimacy scores on relationship satisfaction were significant. The actor effect of EPSI Intimacy scores on depression was consistent; however, the partner effect was not. In the model of primary interest, both actor and partner effects of relationship satisfaction on depression were significant; in this equivalent model, both the actor and partner effects of depression on relationship satisfaction were significant. Notably, in the alternative model specified in Figure 2, relationship satisfaction was regressed on Level II predictors (relationship satisfaction and sexual arrangements) but depression was not. This contrasts with the model of primary interest in which depression was regressed on Level II predictors but relationship satisfaction was not. This variation in specification was necessitated in order to achieve convergence. The results of this alternative model revealed that men with a discrepant relationship arrangement were significantly less satisfied with their relationship than men in monogamous relationships (B = -2.59; 95% CI: -4.18, -1.00; β = -.45, p< .01). Men in open and monogamish arrangements did not differ significantly from one another or from either the monogamous or discrepant groups.

Figure 2.

Figure 2

Open in a new tab

Alternative model 1.

*p≤.05; **p≤.01

The second alternative model considered depression and relationship satisfaction as correlated outcomes without imposing any predictive association on their relationship to one another. In this model, two correlations were calculated between these outcomes. One captured the association between participants’ own depression and relationship satisfaction. The second captured the association between participants’ depression scores and their partners’ relationship satisfaction. This latter correlation is equivalent to the association between participants’ own relationship satisfactions scores and their partner’s depression scores. Results of this model are depicted in Figure 3. Consistent with the model of primary interest, the actor effect of EPSI Intimacy scores on depression was statically significant; the partner effect was not. Meanwhile, both the actor and partner effects of EPSI Intimacy scores on relationship satisfaction were statistically significant. Finally, also consistent with the model of primary interest, both the actor and partner correlations between depression and relationship satisfaction were statistically significant.

Figure 3.

Figure 3

Open in a new tab

Alternative model 2.

*p≤.05; **p≤.01

DISCUSSION

Findings in the current study illustrate the link between intra-individual development and dyadic processes in partnered gay men. Eriksonian intimacy development within the individual was found to be a significant predictor of one’s own relationship satisfaction and depression, as well as of their partners’ relationship satisfaction. Furthermore, results highlight the interdependence between relationship satisfaction and mental health outcomes for gay male couples, as participants’ depression scores were predicted by their partners’ (but not their own) relationship satisfaction scores. Of note, these patterns of associations were observed even when alternative reversed models were considered.

The pattern of observed indirect effects is consistent with the conceptualization of mental health and relationship functioning as outcomes under joint control as defined in CIT. While links between one’s relationship satisfaction and depression have been well-documented in previous studies (e.g., Rehman et al., 2015; Whitton & Kuryluk, 2014), our analyses also uncovered the potent influence of one’s partner (e.g., the partner effects), illustrating the utility of dyadic analyses. A pathway was observed in which Eriksonian intimacy, relationship satisfaction, and mental health were positively correlated within each individual. This pathway encompasses the actor effects of Eriksonian intimacy on relationship satisfaction and relationship satisfaction on depression. At the same time, there was evidence of meaningful partner effects. An individual’s own Eriksonian intimacy score predicted his partner’s relationship satisfaction and partners’ relationship satisfaction in turn predicted respondents’ own depression scores. The presence of these two pathways alone would indicate that relationship functioning and mental health are intertwined in a manner consistent with the notion of joint control (Kelley & Thibaut, 1978; Rusbult & Van Lange, 2003; Rusbult & Van Lange, 2008). This assertion is further supported by the presence of a mixed pathway in which participants’ own Eriksonian intimacy score predicted their relationship satisfaction score while relationship satisfaction scores were, in turn, related to partners’ depression scores.

This pattern of findings can be understood in the context of the accommodation process. Previous research has suggested the process of accommodation is initiated by individual-level factors, and is employed in order to cultivate positive joint outcomes and reconcile conflict (Kelley & Thibaut, 1978; Rusbult et al., 1991; Yovetich & Rusbult, 1994). Ourresults innovatively suggest that an individual’s developmental capacity for intimacy might contribute to the initiation of the accommodation process. Failure to accommodate can lead to negative joint outcomes (i.e. hostility, retaliation, avoidance, etc.) and persistence of the couple’s conflict (Kelley & Thibaut, 1978; Rusbult et al., 1991; Yovetich & Rusbult, 1994) which can contribute to poor mental health outcomes (Mackinnon et al., 2012; Whisman & Uebelacker, 2009). To the extent that individuals with higher levels of intimacy development are more successful in the accommodation process, it would be expected that they would also experience higher levels of relationship satisfaction and lower levels of depression.

These results suggest that interventions to reduce depression for gay men who are in relationships may also benefit from incorporating a focus on relationship quality, whether as a factor that could help with depression or as an end-goal in itself. Such interventions might take on either a couples-based or individual format. Couples-based approaches to the treatment of depression have shown promising results in studies of heterosexual couples (e.g., Bodenmann et al., 2008; Dessaulles, Johnson, & Denton, 2003). While no studies, to our knowledge, have specifically examined couples-based interventions to reduce depression among gay men, behavioral couples therapy (BCT) has shown efficacy in reducing drug use (Fals-Stewart, O’Farrell & Lam, 2009). BCT is founded on the premise that relationship functioning and individual behavioral outcomes are reciprocally linked. Our results suggest that mental health (e.g., depression) is linked to relationship functioning in a manner that is consistent with this assumption, pointing to the potential utility of employing couples-based approaches for depression in gay men.

Consistent with Hoff and colleagues (2010), the current results indicated that discrepant perceptions of sexual arrangement were associated with lower relationship satisfaction. This finding suggests that interventions focused on improving individual outcomes through the mechanism of dyadic functioning might benefit from incorporating a discussion of sexual agreements. The existing protocol from the Centers for Disease Control and Prevention (CDC) for Couples HIV Testing and Counseling (CHTC) provides a model for facilitating this discussion, which might be used broadly by service providers (CDC, 2010). CHTC provides a framework for delivering HIV test results, while also discussing the couple’s relationship, concerns about sexual health risk, sexual agreements, and strategies for handling agreement violations that could easily be integrated into couples’ interventions focused on other outcomes such as depression.

Delivering services to couples presents some unique challenges, such as the need for partners to coordinate their attendance at joint sessions. For some, this is a substantial logistical barrier. For others, one partner may desire services while the other does not. Further, provider-level skill-building and agency-level concerns about service provision and integration may also pose challenges (Stephenson, Grabbe, Sidibe, McWilliams & Sullivan, 2016). In order to maximize their ability to serve gay men in relationships, providers may elect to work with individual partnered men, with a focus on enhancing their emotional capacity to engage in relationships and also on behavioral skills which enhance relationship quality. The therapeutic relationship may indeed provide a valuable context in which clients can learn and practice new skills to increase emotional openness and intimacy, and potentially resolve issues of intimacy and/or other Eriksonian challenges. This work may be particularly beneficial for gay (and other sexual minority) clients whose developmental trajectory through these earlier life stages may have been somewhat delayed by having to conceal their sexual identity or disrupted by experiences of familial rejection (Hammack & Cohler, 2009; Patterson & D’Augelli, 2013). Our results suggest that such individually-delivered interventions have the potential to yield benefits for both partners because of the inter-related and inter-dependent nature of intimacy, dyadic functioning, and mental health.

These results should be understood in light of several limitations. First, this study does not purport to test mediation in a causal sense but rather examined potential indirect effects (see Kline (2015) for a discussion of this distinction) to illustrate the potential utility of future longitudinal studies. Second, the current sample’s generalizability may be limited by the sample being mostly White, relatively well educated, and based in New York City. The application of current findings to other groups, such as lesbian or bisexual women and transgender and gender-nonconforming individuals, warrants future research. Third, the average relationship length in the current study was approximately 5 years. Links among individual intimacy development, relationship satisfaction, and depression may form over time as individuals interact. Future research should examine the potential for developmental evolution in interdependence through longitudinal studies and/or crosssectional sampling strategies that would permit the testing of such hypotheses. Fourth, the current study only assessed Erikson’s intimacy stage. Although this stage was the most theoretically relevant to the current research question, future research could examine how the resolution of earlier stages might contextualize associations with intimacy development. Such research may also benefit from examining associations with later stages of development, which might have greater salience for men beyond the emerging adulthood years. Fifth, future studies might utilize a measure of accommodation (e.g., Finkel & Campbell, 2001; Rusbult et al., 1991) to directly test hypotheses about its potential to explain associations among intimacy, mental health, and relationship functioning. Finally, it should be acknowledged that dyadic studies may inadvertently oversample more highly functioning couples (Starks, Millar, & Parsons, 2015) by virtue of their ability and willingness to coparticipate in a research study. Thus, the current findings may reflect an underrepresentation of poorer functioning couples.

Conclusions

Despite these limitations, this study provides evidence of the interdependence of gay male partners’ mental health, suggesting that individual and dyadic factors are inextricably linked. This was evidenced particularly in the associations between individuals’ intimacy development and relationship satisfaction scores for themselves and their partners. It was also made evident by the fact depression scores were predicted by partners’ (but not one’s own) relationship satisfaction. The patterns reported here suggest a reciprocal association between the personal and the dyadic and provide compelling support for the utility of couples-based interventions for depression in gay men and the use of interpersonal psychotherapy strategies which may enhance skills necessary to develop emotional connections with others.

Public Significance Statement.

This study found that, in gay male relationships, one partner’s depression and relationship satisfaction can be influenced both by their own capacity, and their partner’s capacity, to show intimacy. This ties a developmental feature within the individual to both their own satisfaction in adult relationships and their partner’s satisfaction—and has novel implications for couples-based therapy and individual therapy with gay males who are in romantic relationships.

Acknowledgments

The Couples Project was conducted by the Hunter College Center for HIV/AIDS Educational Studies and Training (CHEST), under the direction of Jeffrey T. Parsons. The authors acknowledge the contributions of other members of the Couples Project Research Team: Drew Mullane, KailipBoonrai, Catherine Jones, Joel Rowe, Anna Johnson, Ruben Jimenez, and Chris Hietikko – and thank the participants involved. Tyrel Starks was supported in part by a National Institute on Drug Abuse grant (R34 DA036419). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

References

  1. Basco MR, Prager KJ, Pita JM, Tamir LM, Stephens JJ. Communication and intimacy in the marriages of depressed patients. Journal of Family Psychology. 1992;6(2):184–194. doi: 10.1037/0893-3200.6.2.184. [DOI] [Google Scholar]
  2. Benazon NR, Coyne JC. Living with a depressed spouse. Journal of Family Psychology. 2000;14(1):71–79. doi: 10.1037/0893-3200.14.1.71. [DOI] [PubMed] [Google Scholar]
  3. Bodenmann G, Plancherel B, Beach SRH, Widmer K, Gabriel B, Meuwly N, Schramm E, et al. Effects ofcoping-oriented couples therapy on depression: A randomized clinical trial. Journal of Consulting and Clinical Psychology. 2008;76(6):944–954. doi: 10.1037/a0013467. [DOI] [PubMed] [Google Scholar]
  4. Centers for Disease Control and Prevention. Couples HIV Counseling and Testing Intervention and Training Curriculum. 2010 Retrieved from https://www.cdc.gov/globalaids/resources/prevention/chct.html.
  5. Christiansen SL, Palkovitz R. Exploring Erikson’s psychosocial theory of development: Generativity and its relationship to paternal identity, intimacy, and involvement in childcare. The Journal of Men’s Studies. 1998;7(1):133–156. doi: 10.3149/jms.0701.133. [DOI] [Google Scholar]
  6. Cook WL, Kenny DA. The actor–partner interdependence model: A model of bidirectional effects in developmental studies. International Journal of Behavioral Development. 2005;29(2):101–109. doi: 10.1080/01650250444000405. [DOI] [Google Scholar]
  7. Cramer D. Relationship satisfaction and conflict style in romantic relationships. The Journal of Psychology. 2000;134(3):337–341. doi: 10.1080/00223980009600873. [DOI] [PubMed] [Google Scholar]
  8. Derogatis LR. Brief Symptom Inventory: Admnistration, Scoring & Procedures Manual. Bloomington, MN: NCS Pearson, Inc; 1993. [Google Scholar]
  9. Derogatis LR, Melisaratos N. The brief symptom inventory: An introductory report. Psychological Medicine. 1983;13(3):595–605. doi: 10.1017/S0033291700048017. [DOI] [PubMed] [Google Scholar]
  10. Dessaulles A, Johnson SM, Denton WH. Emotion-focused therapy for couples in the treatment of depression: A pilot study. American Journal of Family Therapy. 2003;31:345–353. doi: 10.1080/01926180390232266. [DOI] [Google Scholar]
  11. Dubuis-Stadelmann E, Fenton BT, Ferrero F, Preisig M. Spouse similarity for temperament, personality and psychiatric symptomatology. Personality and Individual Differences. 2001;30(7):1095–1112. doi: 10.1016/S0191-8869(00)00092-1. [DOI] [Google Scholar]
  12. Erikson EH. Childhood and society (Rev ed) New York: WW Norton & Company; 1963. [Google Scholar]
  13. Erikson EH. Identity: Youth and crisis. New York: Norton; 1968. [Google Scholar]
  14. Fals-Stewart W, O’Farrell TJ, Lam WKK. Behavioral couples therapy for gay and lesbian couples with alcohol use disorders. Journal of Substance Abuse Treatment. 2009;37(4):379–387. doi: 10.1016/j.jsat.2009.05.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Finkbeiner NM, Epstein NB, Falconier MK. Low intimacy as a mediator between depression and clinic couple relationship satisfaction. Personal Relationships. 2013;20(3):406–421. doi: 10.1111/j.1475-6811.2012.01415.x. [DOI] [Google Scholar]
  16. Finkel EJ, Campbell WK. Self-control and accommodation in close relationships: an interdependence analysis. Journal of Personality and Social Psychology. 2001;81(2):263. doi: 10.1037/0022-3514.81.2.263. [DOI] [PubMed] [Google Scholar]
  17. Galbaud du Fort G, Bland R, Newman S, Boothroyd L. Spouse similarity for lifetime psychiatric history in the general population. Psychological Medicine. 1998;28(4):789–802. doi: 10.1017/S0033291798006795. [DOI] [PubMed] [Google Scholar]
  18. Goodreau SM, Carnegie NB, Vittinghoff E, Lama JR, Sanchez J, Grinsztejn B, Buchbinder SP, et al. What drives the US and Peruvian HIV epidemics in men who have sex with men (MSM)? PLoS ONE. 2012;7(11):e50522. doi: 10.1371/journal.pone.0050522. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Grov C, Starks TJ, Rendina HJ, Parsons JT. Rules About Casual Sex Partners, Relationship Satisfaction, and HIV Risk in Partnered Gay and Bisexual Men. Journal of Sex & Marital Therapy. 2014;40(2):105–122. doi: 10.1080/0092623X.2012.691948. [DOI] [PubMed] [Google Scholar]
  20. Hammack PL, Cohler BJ. The story of sexual identity: Narrative perspectives on the gay and lesbian life course. New York: Oxford University Press; 2009. [Google Scholar]
  21. Hendrick SA. A generic measure of relationship satisfaction. Journal of Marriage and Family. 1988;50:93–98. doi: 10.2307/352430. [DOI] [Google Scholar]
  22. Hoff CC, Beougher SC, Chakravarty D, Darbes LA, Neilands TB. Relationship characteristics and motivations behind agreements among gay male couples: Differences by agreement type and couple serostatus. AIDS Care. 2010;22(7):827–835. doi: 10.1080/09540120903443384. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Kelley HH, Thibaut TW. Interpersonal relations: A theory of interdependence. New York: John Wiley & Sons; 1978. [Google Scholar]
  24. Kenny DA. Models of non-independence in dyadic research. Journal of Social and Personal Relationships. 1996;13:279–294. doi: 10.1177/0265407596132007. [DOI] [Google Scholar]
  25. Kenny DA, Kashy DA, Cook WL. Dyadic data analysis. New York: Guilford Press; 2006. [Google Scholar]
  26. Kline RB. The mediation myth. Basic and Applied Social Psychology. 2015;37(4):202–2013. doi: 10.1080/01973533.2015.1049349. [DOI] [Google Scholar]
  27. Kouros CD, Cummings EM. Longitudinal associations between husbands’ and wives’ depressive symptoms. Journal of Marriage and Family. 2010;72(1):135–147. doi: 10.1111/j.1741-3737.2009.00688.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Ledermann T, Macho S, Kenny DA. Assessing mediation in dyadic data using the actor-partner interdependence model. Structural Equation Modeling: A Multidisciplinary Journal. 2011;18(4):595–612. doi: 10.1080/10705511.2011.607099. [DOI] [Google Scholar]
  29. Leidy NK, Darling-Fisher CS. Reliability and validity of the Modified Erikson Psychosocial Stage Inventory in diverse samples. Western Journal of Nursing Research. 1995;17(2):168–187. doi: 10.1177/019394599501700205. [DOI] [PubMed] [Google Scholar]
  30. Lewis MA, Gladstone E, Schmal S, Darbes LA. Health-related social control and relationship interdependence among gay couples. Health Education Research. 2006;21(4):488–500. doi: 10.1093/her/cyh075. [DOI] [PubMed] [Google Scholar]
  31. Mackinnon SP, Sherry SB, Antony MM, Stewart SH, Sherry DL, Hartling N. Caught in a bad romance: Perfectionism, conflict, and depression in romantic relationships. Journal of Family Psychology. 2012;26(2):215–255. doi: 10.1037/a0027402. [DOI] [PubMed] [Google Scholar]
  32. Maes HH, Neale M, Kendler KS, Hewitt JK, Silberg JL, Foley D, Pickles A, et al. Assortative mating for major psychiatric diagnoses in two population-based samples. Psychological Medicine. 1998;28(6):1389–1401. doi: 10.1017/S0033291798007326. [DOI] [PubMed] [Google Scholar]
  33. McLeod JD. Social and psychological bases of homogamy for common psychiatric disorders. Journal of Marriage and the Family. 1995;57(1):201–214. doi: 10.2307/353828. [DOI] [Google Scholar]
  34. Mitchell JW, Boyd C, McCabe S, Stephenson R. A cause for concern: Male couples’ sexual agreements and their use of substances with sex. AIDS and Behavior. 2014;18(7):1401–1411. doi: 10.1007/s10461-014-0736-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Moss BF, Schwebel AI. Defining intimacy in romantic relationships. Family Relations. 1993;42:31–37. doi: 10.2307/584918. [DOI] [Google Scholar]
  36. Muthen LK, Muthen BO. Mplus user’s guide. 5. Los Angeles, CA: Muthen & Muthen; 2010. [Google Scholar]
  37. Parsons JT, Starks TJ, Dubois S, Grov C, Golub SA. Alternatives to monogamy among gay male couples in a community survey: Implications for mental health and sexual risk. Archives of Sexual Behavior. 2013;42(2):303–312. doi: 10.1007/s10508-011-9885-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Parsons JT, Starks TJ, Gamarel KE, Grov C. (Non)monogamy and sexual relationship quality among same-sex male couples. Journal of Family Psychology. 2012;26(5):669–677. doi: 10.1037/a0029561. [DOI] [PubMed] [Google Scholar]
  39. Patterson CJ, D’Augelli AR. Handbook of psychology and sexual orientation. New York: Oxford University Press; 2013. [Google Scholar]
  40. Rehman US, Evraire LE, Karimiha G, Goodnight JA. Actor-partner effects and the differential roles of depression and anxiety in intimate relationships: A cross-sectional and longitudinal analysis. Journal of Clinical Psychology. 2015;7(7):715–724. doi: 10.1002/jclp.22162. [DOI] [PubMed] [Google Scholar]
  41. Rosenthal DA, Gurney RM, Moore SM. From trust on intimacy: A new inventory for examining erikson’s stages of psychosocial development. Journal of Youth and Adolescence. 1981;10(6):525–537. doi: 10.1007/BF02087944. [DOI] [PubMed] [Google Scholar]
  42. Rusbult CE, Bissonnette VL, Arriaga XB, Cox CL. Accommodation processes during the early years of marriage. In: Bradbury TN, editor. The developmental course of marital dysfunction. New York, NY, US: Cambridge University Press; 1998. pp. 74–113. [DOI] [Google Scholar]
  43. Rusbult CE, Van Lange PA. Interdependence, interaction, and relationships. Annual Review of Psychology. 2003;54:351–375. doi: 10.1146/annurev.psych.54.101601.145059. [DOI] [PubMed] [Google Scholar]
  44. Rusbult CE, Van Lange PA. Why we need interdependence theory. Social and Personality Psychology Compass. 2008;2(5):2049–2070. doi: 10.1111/j.1751-9004.2008.00147.x. [DOI] [Google Scholar]
  45. Rusbult CE, Verette J, Whitney GA, Slovik LF, Lipkus I. Accommodation processes in close relationships: Theory and preliminary empirical evidence. Journal of Personality and Social Psychology. 1991;60(1):53–78. doi: 10.1037/0022-3514.60.1.53. [DOI] [Google Scholar]
  46. Rusbult CE, Yovetich NA, Verette J. An interdependence analysis of accommodation processes. In: Fletcher GO, Fitness J, editors. Knowledge structures in close relationships: A social psychological approach. Hillsdale, NJ, US: Lawrence Erlbaum Associates, Inc; 1996. pp. 63–90. [Google Scholar]
  47. Sandor D, Rosenthal DA. Youths’ outlooks on love: Is it just a stage or two? Journal of Adolescent Research. 1986;1(2):199–212. doi: 10.1177/074355488612006. [DOI] [Google Scholar]
  48. Starks TJ, Millar B, Parsons JT. Correlates of individual versus joint participation in online survey research with same-sex male couples. AIDS and Behavior. 2015;19:963–969. doi: 10.1007/s10461-014-0962-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Stephenson R, Grabbe KL, Sidibe T, McWilliams A, Sullivan PS. Technical assistance needs for successful implementation fo couples HIV testing and counseling (CHTC) intervention for male couples at US HIV testing sites. AIDS and Behavior. 2016;20:841–847. doi: 10.1007/s10461-015-1150-7. [DOI] [PubMed] [Google Scholar]
  50. Sullivan PS, Salazar L, Buchbinder S, Sanchez TH. Estimating the proportion of HIV transmissions from main sex partners among men who have sex with men in five US cities. AIDS. 2009;23(9):1153–1162. doi: 10.1097/QAD.0b013e32832baa34. [DOI] [PubMed] [Google Scholar]
  51. Teichman Y, Bar-El Z, Shor H, Elizur A. Cognitive, interpersonal, and behavioral predictors of patients’ and spouses’ depression. Journal of Affective Disorders. 2003;74(3):247–256. doi: 10.1016/S0165-0327(02)00015-0. [DOI] [PubMed] [Google Scholar]
  52. Van Orden KA, Braithwaite S, Anestis M, Timmons KA, Fincham F, Joiner TE, Lewinsohn PM. An exploratory investigation of marital functioning and order of spousal onset in couples concordant for psychopathology. Journal of Marital and Family Therapy. 2012;38(s1):308–319. doi: 10.1111/j.1752-0606.2011.00277.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Wester SR, Pionke DR, Vogel DL. Male gender role conflict, gay men, and same-sex romantic relationships. Psychology of Men and Masculinity. 2005;6(3):195–208. [Google Scholar]
  54. Whisman MA. The association between depression and marital dissatisfaction. In: Beach SRH, editor. Marital and family processes in depression: A scientific foundation for clinical practice. Washington, DC: American Psychological Association; 2001. pp. 3–24. [DOI] [Google Scholar]
  55. Whisman MA, Uebelacker LA. Prospective associations between marital discord and depressive symptoms in middle-aged and older adults. Psychology and Aging. 2009;24(1):184–189. doi: 10.1037/a0014759. [DOI] [PubMed] [Google Scholar]
  56. Whisman MA, Uebelacker LA, Weinstock LM. Psychopathology and marital satisfaction: the importance of evaluating both partners. Journal of Consulting and Clinical Psychology. 2004;72(5):830–838. doi: 10.1037/0022-006X.72.5.830. [DOI] [PubMed] [Google Scholar]
  57. Whitton SW, Kuryluk AD. Relationship satisfaction and depressive symptoms in emerging adults: Cross-sectional associations and moderating effects of relationship characteristics. Journal of Family Psychology. 2012;26(2):226–235. doi: 10.1037/a0027267. [DOI] [PubMed] [Google Scholar]
  58. Whitton SW, Kuryluk AD. Associations between relationship quality and depressive symptoms in same-sex couples. Journal of Family Psychology. 2014;28(4):571–576. doi: 10.1037/fam0000011. [DOI] [PubMed] [Google Scholar]
  59. Yovetich NA, Rusbult CE. Accommodative behavior in close relationships: Exploring transformation of motivation. Journal of Experimental Social Psychology. 1994;30(2):138–164. doi: 10.1006/jesp.1994.1007. [DOI] [Google Scholar]

RESOURCES