AIDS and Behavior

, Volume 11, Issue 2, pp 299–311

Avoidance, Anxiety, and Sex: The Influence of Romantic Attachment on HIV-Risk among Pregnant Women

  • Trace S. Kershaw
  • Stephanie Milan
  • Claire Westdahl
  • Jessica Lewis
  • Sharon Schindler Rising
  • Rachel Fletcher
  • Jeannette Ickovics
Original Paper


Most unprotected sex occurs in close relationships. However, few studies examine relational factors and sexual risk among high-risk populations. Romantic Attachment Theory states that individuals have cognitive working models for relationships that influence expectations, affect, and behavior. We investigated the influence of attachment avoidance and anxiety on sexual beliefs (e.g., condom use beliefs, self-efficacy), behavior (e.g., condom use, multiple partners, unprotected sex with risky partners), and sexually transmitted infections (STIs) among 755 high-risk, young pregnant women (ages 14–25) recruited from urban prenatal clinics. Attachment anxiety predicted sexual beliefs, condom use, and unprotected sex with risky partners controlling for demographic variables. Sexual beliefs did not mediate the relationship between attachment orientation and sexual behavior. Current relationship with the father of the baby did mediate the effect of attachment anxiety on multiple partners and STIs. Results indicate the importance of including general relational factors, such as attachment, in HIV prevention.


HIV risk Attachment Condom use Pregnancy 


  1. Ainsworth, M. D. S. (1982). Attachment: Retrospect and prospect. In C. M. Parkes, & J. Stevenson-Hinde (Eds.), The place of attachment in human behavior (pp. 3–30). New York: Basic Books.Google Scholar
  2. Baron, R. M., & Kenny, D. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistic considerations. Journal of Personality and Social Psychology, 51, 1173–1182.PubMedCrossRefGoogle Scholar
  3. Basen-Engquist, K., Masse, L. C., Coyle, K., Kirby, D., Parcel, G. S., Banspach, S., et al. (1999). Validity of scales measuring the psychosocial determinants of HIV/STD-related risk behavior in adolescents. Health Education Research, 14, 25–38.PubMedCrossRefGoogle Scholar
  4. Begley, E., Crosby, R. A., DiClemente, R. J., Wingood, G. M., & Rose, E. (2003). Older partners and STD prevalence among pregnant African American teens. Sexually Transmitted Diseases, 30, 211–213.PubMedCrossRefGoogle Scholar
  5. Bogaert, A. F., & Sadava, S. (2002). Adult attachment and sexual behavior. Personal Relationships, 9, 191–204.CrossRefGoogle Scholar
  6. Bost, K. K., Cox, M. J., Burchinal, M. R., & Payne, C. (2002). Structural and supportive changes in couples’ family and friendship networks across the transition to parenthood. Journal of Marriage and the Family, 64, 517–531.CrossRefGoogle Scholar
  7. Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development. New York, NY: Basic Books.Google Scholar
  8. Brennan, K. A., & Shaver, P. R. (1995). Dimensions of adult attachment, affect regulation, and romantic relationship functioning. Personality and Social Psychology Bulletin, 21, 267–283.CrossRefGoogle Scholar
  9. Brennan, K. A., & Shaver, P. R. (1998). Attachment styles and personality disorders: Their connections to each other and to parental divorce, parental death, and perceptions of parental caregiving. Journal of Personality, 66, 835–878.PubMedCrossRefGoogle Scholar
  10. C’de Baca, J., Lapham, S. C., Skipper, B. J., & Watkins, M. L. (1997). Use of computer interview data to test associations between risk factors and pregnancy outcomes. Computers and Biomedical Research, 30, 232–243.PubMedCrossRefGoogle Scholar
  11. Ciesla, J. A., Roberts, J. E., & Hewitt, R. G. (2004). Adult attachment and high-risk sexual behavior among HIV-positive patients. Journal of Applied Social Psychology, 34, 108–124.CrossRefGoogle Scholar
  12. Collins, N., & Read, S. (1990). Adult attachment, working models, and relationship quality in dating couples. Journal of Personality and Social Psychology, 58, 644–663.PubMedCrossRefGoogle Scholar
  13. Cooper, M., Shaver, P. R., & Collins, N. L. (1998). Attachment styles, emotion regulation, and adjustment in adolescence. Journal of Personality and Social Psychology, 74, 1380–1397.PubMedCrossRefGoogle Scholar
  14. Cooper, M. L., Shapiro, C. M., & Powers, A. M. (1998). Motivations for sex and risky sexual behavior among adolescents and young adults: A functional perspective. Journal of Personality and Social Psychology, 75, 1528–1558.PubMedCrossRefGoogle Scholar
  15. Cox, M.J., Paley, B., Payne, C. C., & Burchinal, P. (1999). The transition to parenthood: Marital conflict and withdrawal and parent-infant interaction. In M. Cox & J. Brooks-Gunn (Eds.), Conflict and cohesion in families:Causes and consequences. The advances in family research series (pp. 87–104). Mahwah, NJ: Lawrence Erlbaum.Google Scholar
  16. Crosby, R. A., DiClemente, R. J., Wingood, G. M., Sionean, C., Cobb, B. K., & Harrington, K. (2000). Correlates of unprotected vaginal sex among African American female adolescents: Importance of relationship dynamics. Archives of Pediatric Adolescent Medicine, 154, 893–899.Google Scholar
  17. Des Jarlais, D. C., & Turner, C. V. (1998, 1998). Audio-CASI versus interviewer obtained survey from participants in syringe exchange programs. Paper presented at the North American syringe exchange convention, Baltimore, Maryland.Google Scholar
  18. DiClemente, R. J., Wingood, G. M., Crosby, R. A., Sionean, C., Cobb, B. K., Harrington, K., et al. (2002). Sexual risk behaviors associated with having older sex partners: A study of black adolescent females. Sexually Transmitted Diseases, 29, 20–24.PubMedCrossRefGoogle Scholar
  19. Dulude, D., Belanger, C., Wright, J., & Sabourin, S. (2002). High-risk pregnancies, psychological distress, and dyadic adjustment. Journal of Reproductive and Infant Psychology, 20, 101–124.CrossRefGoogle Scholar
  20. El-Bassel, N., Witte, S. S., Gilbert, L., Sormanti, M., Moreno, C., Pereira, L., et al. (2001). HIV prevention for intimate couples: A relationship-based model. Families, Systems and Health, 19, 379–395.Google Scholar
  21. El-Bassel, N., Witte, S. S., Gilbert, L., Wu, E., Chang, M., Hill, J., et al. (2003). The efficacy of a relationship-based HIV/STD prevention program for heterosexual couples. American Journal of Public Health, 93, 963–969.PubMedGoogle Scholar
  22. El-Bassel, N., Witte, S. S., Gilbert, L., Wu, E., Chang, M., Hill, J., et al. (2005). Long-term effects of an HIV/STI sexual risk reduction intervention for heterosexual couples. AIDS and Behavior, 9, 1–13.PubMedCrossRefGoogle Scholar
  23. Feeney, B. C., & Kirkpatrick, L. A. (1996). Effects of adult attachment and presence of romantic partners on physiological responses to stress. Journal of Personality and Social Psychology, 70, 255–270.PubMedCrossRefGoogle Scholar
  24. Feeney, J. A., Kelly, L., Gallois, C., Peterson, C., & Terry, D. J. (1999). Attachment style, assertive communication, and safer-sex behavior. Journal of Applied Social Psychology, 29, 1964–1983.CrossRefGoogle Scholar
  25. Feeney, J. A., & Noller, P. (2003). Attachment and sexuality in close relationships. In P. Florsheim (Ed.), Adolescent romantic relations and sexual behavior: Theory, research, and practical implications (pp. 137–162). Mahwah, NJ: Lawrence Erlbaum.Google Scholar
  26. Feeney, J. A., Noller, P., & Callan, V. J. (1994). Attachment style, communication and satisfaction in the early years of marriage. In K. Bartholomew, & D. Perlman (Eds.), Attachment processes in adulthood. Advances in personal relationships. PA, US: Jessica Kingsley Publishers, Ltd.Google Scholar
  27. Feeney, J. A., Noller, P., & Patty, J. (1993). Adolescents’ interactions with the opposite sex: Influence of attachment style and gender. Journal of Adolescence, 16, 169–186.PubMedCrossRefGoogle Scholar
  28. Feeney, J. A., Peterson, C., Gallois, C., & Terry, D. J. (2000). Attachment style as a predictor of sexual attitudes and behavior in late adolescence. Psychology and Health, 14, 1105–1122.CrossRefGoogle Scholar
  29. Florsheim, P., Sumida, E., McCann, C., Winstanley, M., Fukui, R., Seefeldt, T., et al. (2003). The transition to parenthood among young African American and Latino couples: Relational predictors of risk for parental dysfunction. Journal of Family Psychology, 17, 65–79.PubMedCrossRefGoogle Scholar
  30. Fortenberry, J. D., Tu, W., Harezlak, J., Katz, B. P., & Orr, D. P. (2002). Condom use as a function of time in new and established adolescent sexual relationships. American Journal of Public Health, 92, 211–213.PubMedGoogle Scholar
  31. Fraley, R. C., & Davis, K. E. (1997). Attachment formation and transfer in young adults’ close friendships and romantic relationships. Personal Relationships, 4, 131–144.CrossRefGoogle Scholar
  32. Furman, W., & Shaffer, L. (2003). The role of romantic relationships in adolescent development. In P. Florsheim (Ed.), Adolescent romantic relations and sexual behavior (pp. 3–22). Mahwah, New Jersey: Lawrence Erlbaum Associates.Google Scholar
  33. Gallo, L. C., & Smith, T. W. (2001). Attachment style in marriage: Adjustment and responses to interaction. Journal of Social and Personal Relationships, 18, 263–289.CrossRefGoogle Scholar
  34. Gentzler, A. L., & Kerns, K. A. (2004). Associations between insecure attachment and sexual experiences. Personal Relationships, 11, 249–265.CrossRefGoogle Scholar
  35. Goldman, A., & Greenberg, L. S. (1992). Comparison if integrated systemic and emotionally focused approaches to couple therapy. Journal of Consulting and Clinical Psychology, 60, 962–969.PubMedCrossRefGoogle Scholar
  36. Greenberg, L. S., & Johnson, S. M. (1986). Affect in marital therapy. Journal of Marital and Family Therapy, 12, 19–23.CrossRefGoogle Scholar
  37. Hazan, C., & Shaver, P. (1987). Romantic love conceptualized as an attachment process. Journal of Personality and Social Psychology, 52, 511–524.PubMedCrossRefGoogle Scholar
  38. Hensley, W. E. (1996). The effect of a ludus love style on sexual experiences. Social Behavior and Personality, 24, 205–212.CrossRefGoogle Scholar
  39. Ickovics, J. R., Niccolai, L. M., Lewis, J. B., Kershaw, T. S., & Ethier, K. A. (2003). High postpartum rates of sexually transmitted infections among teens: Pregnancy as a window of opportunity for prevention. Sexually Transmitted Infections, 79, 469–473.PubMedCrossRefGoogle Scholar
  40. Johnson, S. M., Hunsley, J., Greenberg, L. S., & Schindler, D. (1999). Emotionally focused couples therapy: Status and challenges. Journal of Clinical Psychology:Science and Practice, 6, 67–79.CrossRefGoogle Scholar
  41. Kalichman, S. C., Sarwer, D. B., Johnson, J. R., & Ali, S. A. (1994). Sexual coercion, domestic violence, and negotiating condom use among low-income African American women. Journal of Psychology and Human Sexuality, 6, 93–106.CrossRefGoogle Scholar
  42. Kershaw T. S., Ethier K. A., Milan S., Lewis J. B., Niccolai L. M., Meade C., Ickovics J. R. (2005). The influence of pregnancy, STD, and HIV susceptibility patterns on sexual risk reduction for adolescent females. Journal of Community Psychology, 33, 313–331.CrossRefGoogle Scholar
  43. Kershaw, T. S., Ethier, K. A., Niccolai, L. M., Lewis, J. B., & Ickovics, J. R. (2003). Misperceived risk among female adolescents: Social and psychological factors associated with sexual risk accuracy. Health Psychology, 22, 523–532.PubMedCrossRefGoogle Scholar
  44. Kershaw, T. S., Ickovics, J. R., Lewis, J. B., Niccolai, L. M., Milan, S., & Ethier, K. A. (2004). Sexual risk following a sexually transmitted disease diagnosis: The more things change the more they stay the same. Journal of Behavior Medicine, 27, 445–461.CrossRefGoogle Scholar
  45. Kershaw, T. S., Niccolai, L. M., Ethier, K. A., Lewis, J. B., & Ickovics, J. R. (2003). Perceived susceptibility to pregnancy and sexually transmitted disease among pregnant and nonpregnant adolescents. Journal of Community Psychology, 31, 419–434.CrossRefGoogle Scholar
  46. Kershaw, T. S., Niccolai, L. M., Ickovics, J. R., Lewis, J. B., Meade, C. S., & Ethier, K. A. (2003). Short and long-term impact of adolescent pregnancy on postpartum contraceptive use: Implications for prevention of repeat pregnancy. Journal of Adolescent Health, 33, 359–368.PubMedCrossRefGoogle Scholar
  47. Ketterlinus, R. D., Lamb, M. E., & Nitz, K. (1991). Development and ecological sources of stress among adolescent parents. Family Relations: Interdisciplinary Journal of Applied Family Studies, 40, 435–441.Google Scholar
  48. Latkin, C., Vlahov, D., & Anthony, J. (1993). Socially desirable responding and self-reported HIV infection risk behaviors among intravenous drug users. Addiction, 38, 517–526.CrossRefGoogle Scholar
  49. Lenoir, C. D., & Ellen, J. M. (2004). What you don’t know can hurt you: Perceptions of sex partner concurrency and partner reported behavior. Journal of Adolescent Health, 34, 113.Google Scholar
  50. Meade, C. S., & Ickovics, J. R. (2005). Systematic review of sexual risk among pregnant and mothering teens in the USA: Pregnancy as an opportunity for integrated prevention of STD and repeat pregnancy. Social Science and Medicine, 60, 661–678.PubMedCrossRefGoogle Scholar
  51. Mikulincer, M., & Florian, V. (1999). The association between spouses’ self-reports of attachment styles and representations of family dynamics. Family Process, 38, 69–83.PubMedCrossRefGoogle Scholar
  52. Mikulincer, M., Florian, V., Cowan, P. A., & Cowan, C. P. (2002). Attachment security in couple relationships: A systemic model and its implications for family dynamics. Family Process, 41, 405–434.PubMedCrossRefGoogle Scholar
  53. Miller, W. B., & Pasta, D. J. (2001). Motivational antecedents to contraceptive method change following a pregnancy scare: A couple analysis. Social Biology, 48, 256–277.PubMedGoogle Scholar
  54. Misovich, S. J., Fisher, J. D., & Fisher, W. A. (1997). Close relationships and elevated HIV risk behavior: Evidence and possible underlying psychological processes. Review of General Psychology, 1, 72–107.CrossRefGoogle Scholar
  55. Niccolai, L. M., Ethier, K. A., Kershaw, T. S., Lewis, J. B., & Ickovics, J. R. (2003). Pregnant adolescents at risk: Sexual behaviors and sexually transmitted disease prevalence. American Journal of Obstetrics and Gynecology, 188, 63–70.PubMedCrossRefGoogle Scholar
  56. Niccolai, L. M., Ethier, K. A., Kershaw, T. S., Lewis, J. B., Meade, C. S., & Ickovics, J. R. (2004). New sex partner acquisition and sexually transmitted disease risk among adolescent females. Journal of Adolescent Health, 34, 216–223.PubMedCrossRefGoogle Scholar
  57. Sanford, K. (1997). Two dimensions of adult attachment: Further validation. Journal of Social and Personal Relationships, 14, 133–143.CrossRefGoogle Scholar
  58. Schachner, D. A., & Shaver, P. R. (2004). Attachment dimensions and sexual motives. Personal Relationships, 11, 179–195.CrossRefGoogle Scholar
  59. Sikkema, K. J., Heckman, T. G., Kelly, J. A., Anderson, E. S., Winett, R. A., Solomon, L. J., et al. (1996). HIV risk behaviors among women living in low-income, inner-city housing developments. American Journal of Public Health, 86, 1123–1128.PubMedCrossRefGoogle Scholar
  60. Simpson, J. A., Rholes, W. S., & Phillips, D. (1996). Conflict in close relationships: An attachment perspective. Journal of Personality and Social Psychology, 71, 899–914.PubMedCrossRefGoogle Scholar
  61. Sionean, C., DiClemente, R. J., Wingood, G. M., Crosby, R., Cobb, B. K., Harrington, K., et al. (2002). Psychosocial and behavioral correlates of refusing unwanted sex among African-American adolescent females. Journal of Adolescent Health, 30, 55–63.PubMedCrossRefGoogle Scholar
  62. Sobel, M. E. (1982). Asymptotic intervals for indirect effects in structural equations models. In S. Leinhart (Ed.), Sociological methodology (pp. 290–312). San Francisco: Josey-Bass.Google Scholar
  63. Tracy, J. L., Shaver, P. R., Albino, A. W., & Cooper, M. (2003). Attachment styles and adolescent sexuality. [References]. In Florsheim Paul (Ed.), Dept of Psychology; U Utah (2003) Adolescent romantic relations and sexual behavior: Theory, research, and practical implications (pp. 137–159). Mahwah, NJ: Lawrence Erlbaum Associates, Publishers.Google Scholar
  64. Turner C. F., Ku L., Rogers S. M., Lindberg L. D., Pleack J. H., & Sonenstein, F. L. (1998). Adolescent sexual behavior, drug use, and violence: Increased reporting with computer survey technology. Science, 280, 867–873.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, Inc. 2006

Authors and Affiliations

  • Trace S. Kershaw
    • 1
  • Stephanie Milan
    • 2
  • Claire Westdahl
    • 3
  • Jessica Lewis
    • 1
  • Sharon Schindler Rising
    • 4
  • Rachel Fletcher
    • 5
  • Jeannette Ickovics
    • 1
  1. 1.Department of Epidemiology and Public Health, and Center for Interdisciplinary Research on AIDSYale UniversityNew HavenUSA
  2. 2.Department of PsychologyUniversity of ConnecticutStorrsUSA
  3. 3.Emory UniversityAtlantaUSA
  4. 4.Centering Pregnancy and Parenting AssociationChesireUSA
  5. 5.Macalester CollegeSt. PaulUSA

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