Examinations of the Close Relationship Processes and Health Framework Among Adult and Adolescent Sexual Minority Men

Despite advancements in biomedical preventions for HIV, sexual minority males continue to be disproportionately affected by HIV. Previous research has estimated that up to two thirds of HIV incidence among sexual minority male adults occur between main partners. In the past decade, a growing number of studies and intervention trials have focused on main relationships as a context for HIV. Much of this work has focused on adult relationships and has been grounded in interdependence theory and highlighted the importance of relationship functioning in facilitating the decisions couples make around condom use. Fewer studies, however, have examined the association between attachment and condomless anal sex, and only one study has examined the association between relationship functioning and condomless sex among adolescent sexual minority males specifically. The close relationship processes and health framework, an integration of attachment theory and interdependence theory, that may be useful in studying HIV risk among sexual minority males. At its core, the close relationship processes and health framework describes relationship functioning between main partners as the mechanism that explains the association between attachment and health behaviors. Although this framework has never been used to explore sexual risk taking, a recent narrative review has suggested that indirect effects between attachment and condomless anal sex through relationship functioning may exist. This dissertation builds on that work by testing the close relationship processes and health framework across three studies. The first study is a secondary data analysis of baseline data from the Couple’s Health Project, a dyadic relationship intervention targeting sexual risk taking and substance use. The final sample for this dissertation study included 49 couples (n = 98 partners). On average, participants were 28.62 years old and 41.8% of participants identified their race and ethnicity as non-White. Participants reported on their demographics and completed measures of attachment (Close Relationship Scale-Short Form) and relationship functioning (Multiple Determinates of Relationship Commitment Inventory). Participants also reported on their sexual behaviors for the past 30-days by completing a timeline follow-back with study staff. Actor-Partner Independence Models were utilized to examine the direct and indirect effects of attachment and relationships functioning on the occurrence of condomless anal sex with a casual partner. Results revealed no significant associations between attachment and the occurrence of condomless anal sex with a casual partner, nor between relationship functioning and condomless anal sex. Findings did reveal significant actor and partner effects between attachment and relationship functioning, suggesting that both interpersonal and intrapersonal beliefs about relationships influence one’s relationship functioning. The second study is a secondary data analysis of the pre-COVID-19 baseline data from Project Partner, an individual relationship-based randomized control trial targeting sexual risk taking and substance use. The final sample for this dissertation study included 98 partners. On average, participants were 26.41 years old and 44.9% of participants identified their race and ethnicity as non-White. Participants reported on their demographics and completed measures of attachment (Close Relationship Scale-Short Form) and relationship functioning (Multiple Determinates of Relationship Commitment Inventory). Participants also reported on their sexual behaviors for the past 30-days by completing a timeline follow-back with study staff. Hurdle models were utilized to examine the direct and indirect effects of attachment and relationships functioning on the occurrence of condomless anal sex with a casual partner, and the frequency of condomless anal sex among those who had at least one instance of condomless anal sex in the past 30-days. Results of the hurdle models revealed one significant indirect effect. Avoidant attachment was associated with higher frequency of condomless anal sex with a casual partner through costs in a relationship among those who had at least one instance of condomless anal sex. The final study analyzed data from Project Connect, a cross-sectional, observational study designed to examine relationship characteristics as predictors of sexual behaviors among partnered adolescent sexual minority males. On average, participants were 18.06 years old (range = 15 to 19) and 46% of participants identified their race as non-White. Participants reported on their demographics and completed measures of attachment (Close Relationship Scale-Short Form), relationship functioning (Perceived Relationship Quality Component), and on sexual behaviors including condomless anal sex with both main and casual partners. Structural equation modeling was used to examine the direct and indirect effects of attachment and relationships functioning on the occurrence of condomless anal sex with main and casual partners. Results anxious attachment was a significant predictor of the occurrence of condomless anal sex with a casual partner and relationship quality. No significant indirect effects were found. Combined, findings across these three studies suggest important avenues for research and clinical implications. First, these studies provide limited support for utilizing the close relationship processes and health framework in studies of sexual minority males. Second, these studies highlight the importance of using hurdle models to examine relationship characteristics as predictors of risk among the risky. Finally, the results from study three emphasize the importance of relationships in sexual risk taking among adolescent sexual minority males. Sexual health intervention and prevention programs for adolescent sexual minority males should include modules on relationship education