Attachment Anxiety and Sexual Health

As described in my previous post, attachment anxiety is commonly expressed as concerns about being abandoned or the fear that the self is unworthy of love and acceptance. In this post, I review research that suggests these kinds of beliefs about the self are related to the decisions people make about sex.

I have posted before about the fact that many couples believe that changes in HIV or STI prevention behavior—deciding not to use condoms or quitting that pre-exposure prophylaxis (PrEP) prescription—demonstrate commitment. Sometimes these beliefs increase the risk of sexual HIV transmission.

Anxious attachment and sexual decision-making

Complementary research conducted mostly with cisgender sexual minority men suggests that those who are high on anxious attachment—those most worried that people will not love them or find them good enough—are generally more likely to have anal sex without using a condom (Starks et al., 2017; Starks & Parsons, 2014). In other words, guys who are worried that a boyfriend or partner will think they are not good enough are more likely to agree to have sex “bareback.” The association between attachment anxiety and PrEP is less clear. At least one study suggests that sexual minority men who are worried that HIV prevention will interfere with intimacy are more interested in PrEP (Gamarel & Golub, 2015). Other studies suggest that some worry PrEP signals a lack of trust or commitment in a relationship (Bosco et al., 2021; Starks et al., 2019).

Attachment anxiety even has the potential to connect drug use to sex in relationships. At least one study found that sexual minority men who scored higher on attachment anxiety were also more likely to believe that using drugs facilitated relationships in some way. This included thinking things like “drug use makes it easier to connect with a partner emotionally” or “using drugs while having sex would make it more likely that sex would lead to a relationship.” Those who endorsed these kinds of thoughts were significantly more likely to report using illicit drugs in the previous month (Starks et al., 2015).

What can we do about it?

Notice, challenge, and develop our thinking. It is true that attachment is relatively stable across the lifespan (Fraley, 2002; Pinquart et al., 2013), but relatively stable still means some change is possible, especially over time. Experiences of accepting, stable, rewarding, and appropriately bounded relationships in adulthood can update our expectations about relationships generally. Sure, early experiences continue to matter, but new ones do as well. This also suggests that developing skills that help you be more successful in relationships might also change your expectations about how valuable you are as a relationship partner, moving the needle toward attachment security.

Stand up to discrimination. At least one study of cisgender sexual minority men suggests that experiences of stigma directed at their sexual identity (e.g., homophobia or heterosexism) actually amplifies the association between the fear that condom use inhibits intimacy and condomless sex (Starks et al., 2014). In other words, when people experience a lot of discrimination and rejection because of their sexuality, these beliefs that foregoing HIV prevention shows a partner how much you care about them are even more strongly related to increases in sexual risk-taking.

Standing up to discrimination has the potential to address the challenges of stigma over the long term. More immediately, we can all do more to acknowledge the effects of minority stress on the way people understand and value their sexual self. For those in practice or seeking counseling services, models for affirmative LGBTQ+ cognitive behavioral therapy are available (Pachankis, 2022).

Conclusions

The way we value our sexual selves is a strong predictor of our sexual health. People who are generally worried about whether they are good enough to deserve a partner’s love and trust are also more likely to believe that foregoing HIV prevention (agreeing to have sex without condoms or without using PrEP) is a way to show their commitment to someone. They are also more likely to believe that drug use will make sex more meaningful. Noticing and challenging these beliefs about the sexual self, and the role of discrimination in shaping these beliefs, is one way to affirm LGBTQ+ identity expression and the well-being of LGBTQ+ relationships.

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