Elsevier

Drug and Alcohol Dependence

Volume 153, 1 August 2015, Pages 187-193
Drug and Alcohol Dependence

The role of sexual expectancies of substance use as a mediator between adult attachment and drug use among gay and bisexual men

https://doi.org/10.1016/j.drugalcdep.2015.05.028Get rights and content

Highlights

  • Anxious and avoidant attachment predicted sexual expectancies of substance use.

  • Sexual expectancies of substance were positively associated with recent drug use.

  • Anxious attachment was indirectly associated with drug use through expectancies.

Abstract

Background

Research exploring substance use in gay and bisexual men has increasingly paid attention to interpersonal dynamics and relational concerns associated with the use of substances. The current study explored the role of adult attachment style on drug use as well as the potential mediating role of sexual expectancies of substance use among gay and bisexual men.

Methods

Online survey data were gathered from 122 gay and bisexual men across the U.S., with a mean age of 33 years. All participants were HIV-negative and identified their relationship status as single. Survey measures included attachment style, sexual expectancies of substance use, and recent drug use.

Results

While neither anxious or avoidant attachment were directly associated with the odds of recent drug use, they were positively associated with sexual expectancies of substance use (β = 0.27, p < 0.01, and β = 0.21, p < 0.05) which, in turn, were positively associated with the odds of drug use (expB = 1.09, p < 0.01). Bootstrapping tests of indirect effects revealed a significant indirect relationship between anxious attachment and drug use through sexual expectancies of substance use (β = 0.11, p < 0.05), but not for avoidant attachment.

Conclusions

This study highlights the importance of interpersonal expectancies as motivators for drug use among gay and bisexual men. Sexual expectancies of substance use were associated with drug use and anxious adult attachment was associated indirectly with drug use through these sexual expectancies.

Introduction

Substance use among gay and bisexual men has remained a prominent focus of research in recent decades. Generally, the literature has indicated high rates of substance use among individuals in this population compared to heterosexuals (Austin and Bozick, 2011, Drabble et al., 2005, Marshal et al., 2009). Utilizing data from over 34,000 people in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC, Wave 2) survey, McCabe et al. (2010) observed that the prevalence rate for a recent substance use disorder among gay men (31.4%) was double that of heterosexual men (15.6%). This elevated substance use among gay and bisexual men is especially concerning given established associations between substance use and sexual HIV transmission risk behaviors (Centers for Disease Control and Prevention, 2011Colfax et al., 2004, Mansergh et al., 2008, Parsons et al., 2013).

Investigations of substance use patterns consistently demonstrate the influence of substance use expectancies (Bekman et al., 2011, Halkitis et al., 2007, Looby and Earleywine, 2010). Substance use expectancies are the beliefs an individual holds about the probability of the specific behavioral or experiential outcomes after drinking and/or drug use. Research has identified a range of positive and negative expectancies, including increased sociability, tension reduction, increased aggression or risk behavior, and expectations for a variety of sexual effects, such as enhanced sexuality, increased sexual vulnerability, and increased sexual risk-taking (Abbey et al., 1999; Dermen and Cooper, 1994a; Ham et al., 2005). Sexual expectancies of substance use, then, are the beliefs one holds about the sexual effects of substance use.

Accordingly, understanding individual expectancies about how substance use influences sexual intimacy, pleasure, and risk-taking, has become an important component of research related to motivations for substance use. Sexual expectancies of substance use have been found to be associated with increased substance use generally, among both heterosexual and gay/bisexual samples (e.g. Buckner and Schmidt, 2008, Jones et al., 2001, Mullens et al., 2010, Mullens et al., 2011a, Rohsenow et al., 2004, Schafer and Brown, 1991), as well as substance use directly before or during sex (Dermen and Cooper, 1994b, Hendershot et al., 2010, Wells et al., 2011). Although the majority of expectancy theory studies have concentrated on alcohol, recent research indicates that general expectancies (i.e., not specifically related to sex or intimacy) operate similarly across other substances such as nicotine, opioids, and stimulants (Kouimtsidis et al., 2014).

The link between drug use and sexual expectancies of substance use has been explored in a small number of studies of men who have sex with men (MSM). For example, Bimbi et al. (2006) found that expectancies of sexual risk-taking were correlated with sexual compulsivity, receptive (but not insertive) condomless anal intercourse, romantic obsessions, alcohol use, and drug use. In another study of 252 gay or bisexual men, those with higher sexual expectancies of substance use reported greater numbers of recent casual sex partners after using substances than those with lower sexual expectancies (Wells et al., 2013)—and the effect of expectancies on casual sex after substance use was enhanced by psychological conflict about the use of condoms.

Significantly, most formulations of sexual expectancies involve an interpersonal component relating to expectations that substance use will facilitate emotional and physical intimacy. This component is prominent in concerns about expressing desire to others (e.g., “I’m more likely to let others know I’m attracted to them when I use cannabis”, from Mullens et al., 2010), sociability or being accepted (e.g., “After a few drinks of alcohol I feel closer to a sexual partner,” from Dermen and Cooper, 1994a) and pleasing one's partner sexually (e.g., “My sexual performance is enhanced when using amyl,” from Mullens et al., 2011a). The importance of interpersonal functioning in one's beliefs about the sexual effects of substance use indicates the need to explore underlying interpersonal interaction styles in the associations between sexual expectancies and substance use. As such, research needs to better understand difficulties related to emotional intimacy in order to further contextualize the associations between sexual expectancies and substance use.

One useful framework by which to organize these interpersonal considerations is attachment theory (Hazen and Shaver, 1994). According to attachment theory, early experiences with caregivers inform schemas related to interpersonal bonding that persist into adulthood (Ainsworth et al., 1978, Bowlby, 1969). These schemas are comprised of “working models” of self and of others; that is, the view of whether oneself is likeable and worthy of attention or love, and the view of whether others are trustworthy and reliable, respectively (Bowlby, 1969, Bowlby, 1977). These models may be reinforced or changed across one's lifetime through repeated interactions with caregivers, romantic partners, friends, etc. (Ainsworth, 1985, Bowlby, 1969), and shape an individual's relationships with the same (Bowlby, 1969, Hazen and Shaver, 1987, Hazen and Shaver, 1994). Three types or styles of attachment have been discussed with some consistency throughout the attachment literature: secure, anxious-ambivalent, and avoidant. Relationships with secure attachment are characterized by mutual warmth and reciprocal commitment; anxious-ambivalent, or anxious attachment, is characterized by holding close others in high esteem but fearing that they will abandon them; anxious-avoidant, or avoidant attachment, is characterized by a desire for emotional distance in relationships with others (Ainsworth et al., 1978, Hazen and Shaver, 1994).

Most of the literature on the subject has found a link between both anxious and avoidant attachment and substance use (Caspers et al., 2005, Kassel et al., 2007, Molnar et al., 2010, Thorberg and Lyvers, 2006, Vungkhanching et al., 2004). Though most research has focused on heterosexual adults, links between attachment and substance use have also been found among gay and bisexual emerging adults (Gwadz et al., 2004, Rosario et al., 2014). Finally, while the bulk of the literature has focused on alcohol use, both types of insecure attachment have also been linked with illicit drug use (both lifetime and recent; Caspers et al., 2005, Rosario et al., 2014).

Attachment-related behavior refers to behavior which achieves or maintains proximity to an emotionally significant other (Ainsworth, 1985, Bowlby, 1977). Inherent in this notion is the idea that individuals are motivated to behave in ways that establish a desired degree of proximity to significant individuals in their social world. Existing literature examining mediators of the attachment-substance use link suggest that it may be reasonable to conceptualize substance use as a form of attachment-related behavior. A handful of studies on heterosexual samples have begun to explore psychological mediators that may explain connections between anxious attachment style and substance use; identified mediators include low self-esteem (Kassel et al., 2007), low perceived social support (Caspers et al., 2005), and coping or social facilitation motives for alcohol use (McNally et al., 2003, Molnar et al., 2010). This collection of identified mediators incorporates interpersonal concerns involving negative affect, negative self-evaluation, and anxious expectancies about evaluation from others. Though no mediators of avoidant attachment and substance use have yet been identified, given the established association between avoidant attachment and drinking to reduce emotional dependency on others (Schindler et al., 2005), it is likely that at least some mediators of avoidant attachment and substance use are interpersonal in nature.

To date, no studies have specifically examined expectancies for the effect of substance use on sex and intimacy as potential mediators of the association between adult attachment and substance use among MSM. However, available data support such a potential set of relationships. For instance, among heterosexual individuals, insecure attachment is associated with greater concerns about partner approval with regard to sex, such as feeling doubts about being loved during sex or suspecting one's partner of avoiding sex (e.g., Birnbaum et al., 2006, Brassard et al., 2007). To the degree that individuals expect substance use to improve intimacy and facilitate sexual encounters, it follows that their attachment expectancies would predict their sexual expectancies, and that sexual expectancies may then drive substance use as a relational or sexual strategy. Though most research has focused on heterosexual adults, links between insecure attachment and aspects of sexual relationship quality have been observed among gay and bisexual men as well (Starks and Parsons, 2014). Sexual expectancies of drug use may serve as the link between attachment concerns and the use of drugs to address those sexual concerns.

The existing literature provides evidence suggesting that adult attachment and sexual expectancies of substance use are associated with substance use behavior; however, this literature is limited by a focus on heterosexual populations and a lack of attention to substances other than alcohol (particularly in studies of sexual expectancies). The purpose of the current study was to examine the role of sexual expectancies of substance use as a mediator between attachment style and drug use (excluding alcohol) among gay and bisexual men. Based on previous results, we hypothesized that: (1) there would be a significant and positive association between anxious attachment and the odds of drug use generally; (2) there would be a significant and positive association between anxious attachment and sexual expectancies of substance use; and (3) the indirect pathway from anxious attachment to the odds of drug use through sexual expectancies would be significant. Because the data related to avoidant attachment is relatively more limited, no specific hypotheses were made; however, we anticipated that associations similar to those expected for anxious attachment might be present.

Section snippets

Participants and procedures

Eligible participants included biological men who identified as male, indicated a gay or bisexual orientation, and reported their relationship status as single. Participation was further restricted to individuals who lived in the United States, were 18 or older, reported an HIV-negative serostatus based upon at least one HIV test in the previous 5 years, and had the ability to complete the survey in English.

Data were collected online between March and May, 2014, via ProofPilot, an internet

Results

The exact number of participants who viewed recruitment messages cannot be determined; however, 854 individuals followed the study link and registered with the ProofPilot platform. Of these, 541 (63.3%) were preliminarily eligible (they were at least 18 years old, they were not currently in a relationship, and they were able to complete the survey in English); 535 of these (98.9%) opened the baseline survey and 327 (62.6%) completed it. Of these, 274 (87.8%) reported a US residence; 172 (62.8%)

Discussion

Findings from the current study supported the hypothesis that sexual expectancies of substance use may provide a link between adult attachment expectancies and drug use. The pattern of findings highlights the relevance of interpersonal concerns and motivations for drug use among gay and bisexual men. Furthermore, it supports the use of attachment theory as a framework for conceptualizing motivations for drug use. The current study found a significant relationship between sexual expectancies of

Role of funding source

Data collection was funded through a faculty development award from Pace University. Data analysis was supported in part by a National Institute on Drug Abuse grant (R34 DA036419; PI Starks). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Neither Pace University or NIDA had further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in

Contributors

Tyrel Starks was primarily responsible for the study design. He also was primarily responsible for the development and execution of the analytic plan for the study. In addition, he is the PI on the grant which provided funding during the data analysis and manuscript production phase. Brett Millar, Andrew Tuck, and Brooke Wells were responsible for structuring introduction and discussion sections and contributed to the writing of the entire manuscript. All authors contributed to and have

Conflict of interest statement

The authors declare that they have no conflicts of interest.

Acknowledgements

The authors would like to acknowledge the contributions of the ProofPilot team, including Mathew Amsden, Lochlan McHale, and David Sperber. They would also like to acknowledge the study's media partner, the Huffington Post, especially Noah Michelson. Special thanks also to Julia Bassiri, Jennifer Kierce, Lucio Forte and Storey Day.

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