1

Adult Attachment and Sexual Functioning:

A Review of Past Research jsm_2843 1..9

Christina Stefanou, BA (Hons) and Marita P. McCabe, PhD

School of Psychology, Deakin University, Melbourne, Vic., Australia

DOI: 10.1111/j.1743-6109.2012.02843.x

ABSTRACT

Introduction. The association between adult attachment and sexual functioning is an important area of research.
However, there has been no previous attempt to systematically review the available literature between these
dimensions, and how their interrelationships may vary within different populations.
Aim. To provide an in-depth critical investigation of the literature on the association between adult attachment and
sexual functioning (satisfaction, dysfunction, and behaviors).
Methods. A systematic literature review of research reported in PsychINFO, Scopus, PubMed, and Psychology and
Behavioral Sciences Collection from January 1, 1990 to November 8, 2011.
Results. The results demonstrated that higher levels of anxious and avoidant attachment were related to less
satisfying sexual relationships, higher levels of sexual dysfunction, and different sexual intercourse frequencies and
motivations for sex.
Conclusions. There is a need for further research to target the sexual functioning of males and to incorporate
representative samples (ethnicity, sexual orientation, and relationship status) into the analyses. Moreover, measure-
ment of sexual behavior needs to encompass a range of sexual functioning variables. Stefanou C and McCabe MP.
Adult attachment and sexual functioning: A review of past research. J Sex Med **;**:**–**.
Key Words. Adult Attachment; Sexual Functioning; Review

Introduction [8]. In fact, experienced psychoanalysts and sex

therapists have long explained sexual dysfunction

S exuality is an integral feature of most romantic

relationships [1], yet it can be a source of
relationship instability [2] and separation [3]. In
the United States, 50% of romantic unions end in
dissolution [4] increasing the risk for psychological
and physical health problems in both partners [5].
It is therefore important to better understand the
factors related to sexual functioning in romantic
relationships.
One theoretical framework that is particularly
relevant to relationships and has been extended to
sexuality research is attachment theory [6]. This
theory proposes that early interactions with sig-
nificant others instill expectations and beliefs sub-
sequently shaping cognitions and behaviors with
romantic partners in adulthood [1,7]. It is assumed
that these early attachment bonds are relevant to
emotional and sexual expression in relationships
within the context of attachment to parents [8].
However, empirical research has only recently
begun to explore these associations.
Two independent dimensions explain individual
differences in adult attachment. Attachment-
related anxiety reflects the degree to which
individuals fear rejection and abandonment.
Attachment-related avoidance reflects the degree
to which individuals experience discomfort with
closeness and dependence [9]. Therefore, anxious
attachment is characterized by high anxiety and
low avoidance, avoidant attachment is defined by
low anxiety and high avoidance, and disorganized
attachment is characterized by high anxiety and
avoidance. Hence, individuals who score high on
either or both of these dimensions are insecurely
attached. By contrast, individuals who are low in
both anxiety and avoidance are securely attached

© 2012 International Society for Sexual Medicine J Sex Med **;**:**–**

2 Stefanou and McCabe
(i.e., comfortable with intimacy and dependency)
[10].
Mikulincer and Shaver [11,12] introduced a
model specifying the activation and operation of
the adult attachment system. When attachment
figures are perceived as available and responsive, a
sense of felt security is developed which encour-
ages the formation of close bonds with others.
However, if attachment figures are perceived as
unavailable and unresponsive, secondary attach-
ment strategies are activated to cope with the
sense of insecurity [1]. Under a hyperactivating
strategy, attachment figures are judged as in-
consistently available, and attachment behaviors
become heightened as anxious clinging or aggres-
sion to obtain attention and care (i.e., anxious
attachment) [13]. In contrast, deactivating strate-
gies are activated when attachment figures
are judged as unavailable and attachment needs
are suppressed and self-reliance is learned (i.e.,
avoidant attachment) [13].
It has been proposed that attachment and
sexual behavior are two instinctual systems that
are central to human behavior [14]. Empirical
research indicates that these two systems have
a reciprocal relationship, as attachment styles
shape the way sexual interactions are experienced
[15]. Specifically, smooth functioning of the sexual
system involves the mutual coordination of
both partners’ sexual motives and behaviors [11].
Dysfunctions of the sexual system reflect those
identified for the attachment system, involving
hyperactivating and deactivating strategies [12].
Sexual hyperactivation involves effortful attempts
to encourage a partner to have sex, placing signifi-
cant value on the importance of sex within a
relationship, and adopting a hypervigilant stance
toward perceived sexual rejection. In contrast,
sexual deactivation involves inhibition of sexual
desire, avoidant attitudes toward sex, distanc-
ing from a partner who is interested in sex, and
inhibition of sexual arousal and orgasmic joy [12].
Therefore, the attachment and sexual behavior
systems can impact sexual function and dysfunc-
tion within romantic relationships.
It is important to note that while there may be
distinct attachment styles in infancy that transcend
into adulthood, there are multiple attachment
combinations that can impact the experience of sex
between partners [16]. Therefore, research exam-
ining individual attachment style within a relation-
ship may be confounded by the attachment
interaction, potentially limiting the explanatory
power of the attachment style of the individual.
J Sex Med **;**:**–**
Research into sexual functioning is important
for people’s well-being, as a recent survey in 27
countries found that 58% of females and 57% of
males were dissatisfied with their sex life [17].
Moreover, although estimates are varied (ranging
from 10% to 30%), sexual dysfunctions are con-
sidered highly prevalent worldwide [18]. Finally,
sexual frequency has been identified as the second
most problematic issue in young married couples
[2]. Hence, studies that have explored the associa-
tions between attachment and sexual behavior
have predominately focused on sexual satisfaction
[1,15,19], sexual dysfunction [20–24], and sexual
behaviors (i.e., frequency, motivation, and experi-
ence) [16,25–30]. Given the importance of adult
attachment and sexual behavior, there is a paucity
of research exploring their associations in the
past, although there has been a substantial increase
in research studies in the last decade. There has
been no previous attempt to systematically re-
view the available literature between sexuality
and attachment, and how these relationships may
vary within different populations. Hence, the goal
of this review was to comprehensively evaluate the
literature on adult attachment and sexual function-
ing, focusing specifically on sexual satisfaction,
dysfunction, and behaviors.
Aims
No prior review has examined the relationship
between early attachment bonds and sexual func-
tioning in adulthood. The purpose of the current
review was to: (i) provide an in-depth critical
investigation of the interrelationships among these
important aspects of sexual functioning; and (ii)
examine the strengths and weaknesses of this
literature, from January 1, 1990 to November 8,
2011, focusing specifically on research design,
samples, measurement, and outcomes.
Methods of Review
Search Strategy
Identification of relevant studies occurred in
a two-stage process. First, electronic databases
used to conduct literature searches included:
PsychINFO, Scopus, PubMed, and Psychology
and Behavioral Sciences Collection (January 1,
1990–November 8, 2011). The search was limited
to English articles (both qualitative and quantita-
tive) and to an adult age group (18 years and
older). A variety of keywords were used to access
sexual functioning variables, and these were used
Review Adult Attachment and Sexual Functioning
separately and in combination. Keywords used to
search titles and abstracts included adult attach-
ment, OR attachment anxi*, OR attachment avoidan*,
OR attachment theory, AND sex*, AND sex* behavio*,
AND sex* problems, AND sex* satisfaction, AND sex*
dysfunction, OR sex* pain, OR orgasm, OR erect*, OR
ejaculat*.
Second, abstracts of identified records were
screened for relevance according to the inclusion
criteria outlined below. Considering that not
all abstracts highlighted the attachment and sexual
functioning strategies used, short-listed articles
were retrieved in full and the method sections
were examined against these criteria. The refer-
ence lists of relevant articles were screened for
identification of additional relevant studies that
may have been missed using the search strategy
listed above.
Inclusion Criteria
Retrieved studies were retained if they included
adult samples of men, women, or both which
examined the association between adult attach-
ment and sexual functioning (behaviors, satisfac-
tion, and dysfunction). Studies were not retained if
they included sexual behaviors beyond frequency,
motivation, and experience. Studies were excluded
if they did not differentiate between the insecure
attachment styles. Only the areas concerning the
association between attachment and sexual func-
tioning were extracted from the reviewed studies,
despite many of them having other key findings or
a wider focus.
Results
Electronic database searching yielded 827 records.
Only studies that investigated adult attachment
and sexual functioning were eligible for inclusion
in this review, which left a total of 15 studies using
the above criteria. The details of the 15 articles are
included in Table 1. The following sections sum-
marize the research design, samples, and measures,
followed by a consideration of the study outcomes.
Study Characteristics and Design
Recruitment
The studies were predominately from the United
States (N = 7), with three studies from Canada,
three from Israel, and two from the United
Kingdom (see Table 2). The most common loca-
tions from which participants were recruited were
universities, community centers, local newspapers,
3
and the Internet. Most studies specified an age
limit of 18+, while three studies began recruit-
ment at 15+ [19,27] and 17+ [28]. Eight studies
had inclusion criteria of participants being in a
current dating, cohabiting, or married partner-
ship [1,15,16,23,24,26,28,29], and two studies had
cutoff age limits at 29 [25] and 35 [26].
Sample Characteristics
Mean ages of participants ranged from 20 to 45.
Four studies used either married or cohabiting
participants [1,16,26,29], and six studies had
female participants [15,20–24]. Most of the
studies reported predominately Caucasian/white
participants [1,19–21,23–27,29]. Two studies did
not mention ethnicity in their sample [15,16].
Eight studies sampled only heterosexual partici-
pants [1,15,16,23,24,26,28,29], three studies did
not specify sexual orientation [19,22,25], and the
remaining four studies had mostly heterosexual
participants [20,21,27,30]. The mean relation-
ship duration ranged from 1 month to 53 years
[1,15,16,20,23,24,26,28,29]. Six studies did not
measure relationship duration [19,21,22,25,27,30].
Study Quality
Samples sizes ranged from 70 to 1,999, with
11 studies having final samples over 200
[1,16,19,21,23–27,29,30]. All studies used self-
report measures of attachment and sexual func-
tioning. The experimental design of 13 of the
reviewed studies was quantitative cross-sectional.
However, two studies [16,29] were longitudinal, as
they employed daily diary measures to monitor
couple’s sexual experience over a period of 7 and
42 days.
Outcome Measures
Outcome measures employed to investigate
the relationship between attachment and sexual
functioning were questionnaire-based. All of
the studies used self-report measures of sexual
functioning and attachment. While the types of
sex measures varied greatly, they most commonly
addressed sexual frequency, sexual problems,
sexual satisfaction, sexual motivations, and sexual
goals. Table 2 only lists measures that are relevant
to adult attachment and sexual functioning.
Adult Attachment Measures
All of the reviewed studies employed measures
which distinguished between Hazan and Shaver’s
[34] prototypical descriptions of the attachment
styles (i.e., secure, anxious, and avoidant). Twelve
J Sex Med **;**:**–**
4 Stefanou and McCabe

Table 1 Sample size and characteristics

Study Sample size and age range Ethnicity Marital status Relationship duration Sexual orientation

Birnbaum, Reis, (Study 1) N: 500 (276 males, 224 Not specified (Study 1) 68.8% (N = 344) 1–96 months Heterosexual
Mikulincer, females) M age = 27.3 currently in a relationship and (M = 19.91 months)
Gillath, and (Study 2) N: 41 cohabiting couples 31.4% were married 6–138 months
Orpaz, 2006 M age males = 26.58 (Study 2) 61% were cohabiting (M = 44.73)
[24] M age females = 25.97 and 39% were married
Birnbaum, 2007 N: 96 women Not specified All participants were currently 3–540 months Heterosexual
[15] M age = 44.95 (ranging 24–67) involved in a romantic (M = 234 months)
relationship (16.7% dating,
69.8% married, 13.5%
separated, divorced, or
widowed).
Bogaert and N: 792 (327 males, 465 females) 61.8% Canadian 72% in a relationship Not specified Not specified
Sadava, 2002 M age = 28.0 (ranging 19–35) 8.2% none 27% single
[25] 1% Asian
29.4% not specified
Brassard, Shaver, N: 273 couples married or French Canadian 29.3% married M = 5 years Heterosexual
and Lussier, cohabiting for at least 6 months 70.7% cohabiting
2007 [26] (273 males, 273 females)
Age range: 18–35
M age males = 27.87
M age females = 30.11
Butzer and N: 116 married couples Canadian All married Marriage ranging from Heterosexual
Campbell, 2008 M age males = 38.56 2 months to 53
[1] M age females = 36.7 years (M = 10.2
years)
Cohen and Belsky, N: 323 females 74% North American, 62% going steady, cohabiting, Not specified 86% heterosexual
2008 [20] M = 24.39 (ranging 18–55) British, Scottish, or Welsh engaged, or married 14% other
26% other 38% other
Costa and Brody, N: 70 females (university 52.2% Scottish 72.9% in a relationship M = 55.43 months 85.5% heterosexual
2011 [19] population) 5.8% other United Kingdom 5.7% unsure 11.6% “mostly”
M age: 25.67 36.2% other Europe 21.4% single heterosexual
5.8% rest of the world 2.9% equal same and
opposite sex
Davis, Shaver, N: 1,999 (757 males, 1,241 77.4% Caucasian Not specified Not specified 85.5% heterosexual
and Vernon, females) 1 sex unspecified 5.4% African American 3.1% homosexual
2004 [27] M age = 25.52 (ranging 15–78) 4.9% Hispanic 9.8% bisexual
3.8% Asian
1% American Indian
6.8% other
Davis et al., 2006 N: 1,989 (724 males, 1,221 78.4% Caucasian 1,006 in a relationship Not specified Not specified
[18] females, 44 sex unspecified) 6.6% African American 983 single
M age = 25.46 (ranging 15–75) 4.7% Hispanic
3.7% Asian
1.1% American Indian
5.1% other
0.3% unspecified
Granot, N: 110 females (45 with Israeli Dyspareunia group (31 single, Not specified Not specified
Zisman-Ilani, dyspareunia and 65 controls) 14 married or cohabiting)
Ram, Goldstick, Dyspareunia group (M = age 25.5) Control group (44 single, 18
and Yovell, 2011 Control group (M = age 27.22) married or cohabiting, 3
[21] divorced)
Impett, Gordon, N: 84 undergraduates (37 males, 1% African American All currently involved in a M = 1 year 7 months Heterosexual
and Strachman, 47 females) 39% Asian romantic relationship
2008 [28] M age = 20.3 (ranging 17–38) 14% Hispanic
39% Caucasian
7% other
Little, McNulty, N: 72 newlyweds in Study 1 91–96% Caucasian All married Not specified Heterosexual
and Russell, M age males = 24.92
2010 [29] M age females = 23.54
N: 135 newlyweds in Study 2
M age males = 25.90
M age females = 24.21
Schachner and N: 232 undergraduates (64 males, 39.2% Asian 96.1% unmarried Not specified 93.5% heterosexual
Shaver, 2004 167 females, 1 unspecified) 35.8% Caucasian (13.8% single, 64.2% in a
[30] M age = 20 (range 18–30) 7.8% Hispanic relationship)
3% African American
13.3% other
Stephenson and N: 200 female undergraduates 54.5% European American All in a relationship M = 20.93 months Heterosexual
Meston, 2010 M age = 20.25 17.7% Hispanic
[22] 16.4% Asian
4.5% African
5.9% other
Stephenson and N: 200 female undergraduates 54.5% European American All in a relationship M = 20.93 months Heterosexual
Meston, 2011 M age = 20.25 17.7% Hispanic
[23] 16.4% Asian
4.5% African
5.9% other

J Sex Med **;**:**–**

 Table 2 Recruitment and outcomes of included studies
Adult attachment Sexual functioning variables targeted
Study Recruitment measurement and their measurement Outcomes

Birnbaum, Reis, Mikulincer,
Gillath, and Orpaz, 2006
[24] (Israel)
Birnbaum, 2007 [15] (Israel)
Bogaert and Sadava, 2002
[25] (Canada)
Brassard, Shaver, and Lussier,
2007 [26] (Canada)
Butzer and Campbell, 2008 [1]
(Canada)
Cohen and Belsky, 2008 [20]
(United Kingdom)
Costa and Brody, 2011 [19]
(United Kingdom)
(Study 1) universities and
community centers
(Study 2) flyers, universities,
community centers, sport clubs
Community centers
Random digit-dialing techniques to
households seeking individuals
between 20 and 29
Random digit-dialing seeking
individuals between 18 and 35
Newspaper advertisement
Internet advertisement
University
Mikulincer et al. [31] adult (Study 1) 3 scales measuring experience of (Study 1): anxious attachment was associated with an ambivalent construal of
attachment scale sexual intercourse (relationship centered, sexual experience, and avoidant attachment was related to aversive sexual
worry centered, and pleasure centered) feelings and cognitions.
(Study 2) Sex diary measure (Study 2): anxiously attached females equated sex with love (contrasted with
anxiously attached men), and avoidantly attached individuals separated sex from
love (with no gender differences).
Hebrew version of the ISBI and WSWMS Anxiously attached females experienced less sexual arousal, intimacy, orgasm, and
ECR sexual satisfaction.
Avoidantly attached females experienced less sexual intimacy, arousal, and
excitement with no sexual satisfaction link.
Simpson [32] adult Series of direct questions measuring sexual Anxiously attached individuals had higher rates of erotophilia, whereas avoidantly
attachment measure experience, and the Sexual Opinion attached individuals had lower frequency of sexual intercourse.
Survey
ECR 5 direct questions to measure sexual Anxious and avoidantly attached individuals experienced more sexual problems
experience (e.g., with erection or lubrication). Avoidant attachment was related to lower
sexual frequency, whereas anxious attachment was related to higher sexual
frequency.
ECR ENRICH sexual relationship subscale, and Anxious and avoidantly attached individuals reported lower sexual satisfaction.
the ISSS
ECR Specific measure developed to assess Higher levels of avoidant attachment predicted lower levels of orgasmic frequency.
female orgasmic frequency
ECR Direct questions regarding sexual behaviors Anxious attachment was associated with less vaginal orgasms. Avoidant attachment
(frequency and orgasm) had a nonsignificant trend toward being related to less vaginal orgasms.
Review Adult Attachment and Sexual Functioning

Davis, Shaver, and Vernon,
2004 [27] (United States)
Davis et al., 2006 [18] (United
States)
Granot, Zisman-Ilani, Ram,
Goldstick, and Yovell, 2011
[21] (Israel)
Impett, Gordon, and
Strachman, 2008 [28]
(United States)
Little, McNulty, and Russell,
2010 [29] (United States)
Schachner and Shaver, 2004
[30] (United States)
Stephenson and Meston, 2010
[22] (United States)
Stephenson and Meston, 2011
[23] (United States)
Internet advertisement ECR AMORE Anxious attachment was positively related to sexual motivation and to all specific
motives for sex (except physical pleasure).
Avoidant attachment was negatively related to emotional closeness and reassurance
as goals for sex, and positively related to manipulative use of sex.
Internet advertisement ECR Sexual satisfaction assessed in terms of Anxious and avoidant attachment were associated to higher levels of sexual anxiety
three separate constructs (physical, and dissatisfying sexual outcomes.
emotional, and satisfaction with control)
Unspecified ECR Self-reported painful intercourse to Dyspareunia group showed greater incidence, compared with the control group, of
determine dyspareunia anxious and avoidant attachment.
University ECR 10-item measure of sexual goals adapted Anxious attachment was associated with engaging in sex to please one’s partner
from Cooper, Shapiro, and Powers (1998) and express love, whereas avoidant attachment was associated with engaging in
[33] sex to avoid negative relational consequences and was negatively related with
engaging in sex to express love.
Newspaper advertisements and ECR Direct questions to measure sexual Anxious and avoidant attachment was negatively related to sexual satisfaction in
invitations were sent to couples frequency and satisfaction (diary both studies. Insecure attachment was not related to sexual frequency in both
who had completed marriage measures) studies.
license applications.
University ECR AMORE Anxious attached was associated with having sex to reduce insecurity and foster
intense intimacy.
Avoidant attached was inversely related with having sex to foster intimacy and
positively related to non-romantic goals (e.g., sex to increase status).
University ECR FSFI Sexual pain and difficulties with lubrication were associated with greater sexual
distress only for more anxiously attached women in low intimacy relationships.
University ECR FSFI Anxious attachment moderated the indirect effect wherein sexual functioning
accounted for the association between sexual costs and sexual satisfaction.

ECR = Experiences in Close Relationships Scale; FSFI = Female Sexual Function Index; AMORE = Affective and Motivational Orientation Related to Erotic Arousal; ISBI = Israeli Sexual Behavior Inventory; WSWMS = Women’s Sexual Working Model Scale; ENRICH = Enriching and Nurturing
Relationship Issues, Communication, and Happiness; ISSS = Index of Sexual Satisfaction Scale

J Sex Med **;**:**–**

5
6 Stefanou and McCabe
studies used the Experiences in Close Relationships
(ECR) scale [35], and one study [15] used a Hebrew
version of the ECR. One study [25] used an attach-
ment measure developed by Simpson [32], and
another study [16] used an attachment measure
developed by Mikulincer et al. [31]. All of the
attachment measures employed had robust psy-
chometric properties. One study only measured
avoidant attachment in their study [21], and two
studies only examined anxious attachment [23,24].
None of the studies measured disorganized attach-
ment, and so the impact of this category on sexual
functioning has not been examined.
Sexual Functioning Measures
Ten studies used a measure directly related to
sexual functioning, and five studies developed
direct questions to assess sexual experience
[20,22,25,26,29]. Two studies used daily diary
entries to monitor sexual frequency [16,29]. Two
studies used a female sexual functioning specific
measure, the Female Sexual Functioning Index
(FSFI) [23,24], and one study developed a specific
measure for female orgasmic frequency [21].
Mediators and Moderators
A variety of mediator and moderator variables were
found in the relationship between adult attachment
and sexual functioning. Specifically, Stephenson
and Meston [22] found that sexual pain and
difficulties with lubrication were associated with
greater sexual distress only for more anxiously
attached females in low intimacy relationships.
Moreover, Stephenson et al. [23] found that sexual
functioning accounted for the association between
sexual costs (i.e., exchanges that demand effort or
cause pain, anxiety, or other negative affect) and
sexual satisfaction only for females reporting low
levels of anxious attachment. Additionally, Bogaert
and Sadava [25] found that gender moderated the
relationship between adult attachment and sexual-
ity, such that most of the association between the
two variables in the full sample was determined by
women.
Birnbaum [15] found that sexual satisfaction
mediated the association between anxious attach-
ment and relationship satisfaction. Furthermore,
Davis et al. [18] found that the relationship be-
tween insecure attachment and sexual dissatisfac-
tion was mediated by inhibited communication of
sexual needs. Little et al. [29] found that expectan-
cies for partner availability mediated the effects
between insecure attachment and sexual frequency.
The only study to use Body Mass Index as a poten-
J Sex Med **;**:**–**
tial moderator variable between female sexual func-
tioning and avoidant attachment did not find any
significant effects [20].
Discussion
The aim of the present article was to examine the
strengths and weaknesses of the literature on adult
attachment and sexual functioning, and provide
an in-depth critical investigation of the inter-
relationships among these variables. In total, 15
studies were reviewed in which some aspect of
sexual functioning was related to adult attachment.
This discussion will summarize the overall find-
ings of the literature, address the methodological
issues in the reviewed studies, and consider some
suggestions for future research.
Both anxious and avoidant attachment were
found to be consistently associated with less satis-
fying sexual experiences in married, dating, and
homosexual partnerships [1,19,29]. Such results
are in agreement with the theoretical foundations
of attachment theory. However, Birnbaum [15]
found that only anxious attachment was related to
sexual dissatisfaction, with no significant associa-
tions between avoidant attachment. This may
be an artifact of the female sample, which were
older (mean 44.95 years) and in highly committed
relationships. These females may have perceived
their relationship as more functional and satisfac-
tory than other avoidantly attached females typi-
cally participating in research, who are generally
younger and in less committed relationships
[9,15]. Hence, these results may indicate that
avoidantly attached individuals tend to end their
partnerships before they reach the phase of
extreme relational and sexual dissatisfaction [15].
This is in line with past empirical research which
suggests that avoidantly attached individuals
readily exit their relationships as soon as they
become dissatisfied [9]. In contrast, anxiously
attached individuals are likely to remain in dissat-
isfying relationships due to their fears of separa-
tion and abandonment [9].
The studies on female sexuality suggested that
anxious and avoidant attachment are associated
with less sexual arousal [15], problems with lubri-
cation [36], lack of orgasm [20,21], and sexual pain
[22]. Similarly, Brassard et al. [36] found that inse-
curely attached males experienced more erectile
problems compared with securely attached coun-
terparts. Perhaps these problems among men
with an avoidant attachment style are likely to be
more evident with a partner rather than during
Review Adult Attachment and Sexual Functioning
masturbation. Further research is necessary to
determine whether or not this is the case. Addi-
tionally, avoidant attachment is generally associ-
ated with lower intercourse frequency in both
males and females [25,36]. Hence, the hyperacti-
vating and deactivating strategies characterized
within the attachment and sexual behavior systems
significantly impact sexual dysfunction within
romantic relationships. However, Brassard et al.
[26] found that anxiously attached individuals had
higher rates of sexual intercourse, possibly to
establish intense closeness and reduce insecurities.
Consistent with this proposal, several studies
found that anxiously attached individuals equated
sex with romantic love and have sex to reduce
insecurity and foster intimacy [16,27,28,30]. In
contrast, avoidantly attached individuals viewed
sex and love as distinct components and experience
discomfort with intimacy [16,27,28,30]. These
findings typify the secondary attachment strategies
described earlier. Birnbaum [24] found that anx-
iously attached individuals relied heavily on their
sexual experiences to assess the quality of their
relationship. Specifically, gratifying sexual experi-
ences were equated with a sense of being loved and
valued which temporarily reduced fears of rejec-
tion. Similarly, disappointing sexual experiences
were viewed as signs of partner disapproval
which evoked fears of abandonment. However,
avoidantly attached individuals, who tend to
detach sex from romantic love, did not use positive
or negative sexual experiences to assess relation-
ship quality [9,16].
Moderator and mediator effects including
gender [25], insecure attachment [23,24], sexual
satisfaction [15], and sexual communication [19]
provided further support for the association be-
tween adult attachment and sexual functioning.
Several limitations need to be considered when
interpreting the findings from the 15 studies. First,
the type and variety of instruments employed to
assess sexual functioning made interpretations of
the findings difficult. Although there was some
consistency between the sexual functioning in-
struments, single-item measures were frequently
employed (i.e., direct questions about sexual expe-
rience), which may have compromised reliability
and validity estimates. This could explain some
of the inconsistencies with the empirical data and
the nonsignificant associations found between
insecure attachment and sexual functioning [15].
Moreover, no study in this review comprehen-
sively included a range of sexual functioning vari-
ables in their assessment.
7
Self-report data were used for all of the studies,
which may have further limited the reliability of
the findings given that social desirability and recall
bias have often been linked to self-report data [37].
Moreover, interview measurements of individual
differences and relationship functioning often
reveal more unique information when compared
with standard self-report questionnaires [38].
There were also limitations related to overall
study sample characteristics. Participants recruited
were mostly heterosexual, married, university
populations, Caucasian, and from Western coun-
tries. This makes it difficult to generalize the
significant results to the wider community. Addi-
tionally, six studies used samples comprised only of
females [15,20–24], further limiting the interpre-
tation of the findings.
From the 15 studies, only four [1,15,26,29]
included both couple members in their research.
Hence, the majority of the studies relied solely
on individual perspectives to describe the dynamic
nature of their relationship. This is a significant
limitation of the research, as there are multiple
combinations of attachment patterns that can
impact the experience of sex between dyads.
Conclusion
In summary, an examination of attachment styles
in adulthood assists researchers to better under-
stand the differences in sexual functioning in both
males and females. Although significant relation-
ships have been identified between attachment
and various aspects of sexual functioning, the data
remain inconclusive. Hence, any significant find-
ings should be treated with caution in light of the
methodological issues outlined in this review.
This review focused on the strengths and
weaknesses of the literature which examined the
association between adult romantic attachment
and sexual functioning. Collectively, the studies
provide a better understanding of the nature of sex
in adult relationships. However, there is a need to
conduct studies with: (i) samples that represent
participants from different ethnicities, sexual ori-
entations, and relationship statuses; (ii) employing
data from both members of the relationship
and examining sexual functioning with different
attachment combinations; (iii) examining the asso-
ciation between sexual functioning and individuals
high on both attachment anxiety and avoidance—
this is an important area to study given the level
of expected psychopathology and sexual dysfunc-
tion in this group; (iv) a more comprehensive
J Sex Med **;**:**–**
8 Stefanou and McCabe
measurement of sexual functioning; (v) more focus
into the sexual functioning of males; and (vi) the
inclusion of preplanned mediator and moderator
variables.
Corresponding Author: Marita P. McCabe, PhD,
School of Psychology, Deakin University, 221 Burwood
Highway, Burwood, Victoria 3125, Australia. Tel: 61
3 9244 6856; Fax: 61 3 9244 6858; E-mail: marita.
mccabe@deakin.edu.au
Conflict of Interest: None.
Statement of Authorship
Category 1
(a) Conception and Design
Marita P. McCabe; Christina Stefanou
(b) Acquisition of Data
Christina Stefanou
(c) Analysis and Interpretation of Data
Christina Stefanou
Category 2
(a) Drafting the Article
Christina Stefanou; Marita P. McCabe
(b) Revising It for Intellectual Content
Marita P. McCabe
Category 3
(a) Final Approval of the Completed Article
Marita P. McCabe
References
1 Butzer B, Campbell L. Adult attachment, sexual satisfaction,
and relationship satisfaction: A study of married couples. Pers
Relatsh 2008;15:141–54.
2 Yabiku ST, Gager CT. Sexual frequency and the stability of
marital and cohabiting unions. J Marriage Fam 2009;71:983–
1000.
3 Risch GS, Riley LA, Lawler MG. Problematic issues in the
early years of marriage: Content for premarital education.
J Psychol Theol 2003;31:253–69.
4 Divorce rate in America. (n.d.) 2012. Available at: http://
www.divorcerate.org (accessed December 15, 2011).
5 Amato PR. The consequences of divorce for adults and chil-
dren. J Marriage Fam 2000;62:1269–87.
6 Mikulincer M, Goodman GS. Dynamics of romantic love:
Attachment, caregiving, and sex. New York: Guilford Press;
2006.
7 Bowlby J. Attachment and loss. Vol. 1. Attachment. New York:
Basic Books; 1969.
8 Scharff DE. How development structures relationships. In:
Levine SB, Risen CB, Althof SE, eds. Handbook of clinical
sexuality for mental health professionals. 2nd edition. New
York: Routledge/Taylor & Francis Group; 2010:73–86.
9 Mikulincer M, Shaver PR. Attachment in adulthood: Struc-
ture, dynamics, and change. New York: Guilford Press; 2007.
10 Shaver PR, Mikulincer M. Attachment-related psychodynam-
ics. Attach Hum Dev 2002;4:133–61.
J Sex Med **;**:**–**
11 Mikulincer M, Shaver PR. The attachment behavioral system
in adulthood: Activation, psychodynamics, and interpersonal
processes. In: Zanna MP, ed. Advances in experimental social
psychology. Vol. 35. San Diego, CA: Elsevier Academic Press;
2003:53–152.
12 Mikulincer M, Shaver PR. A behavioral systems perspective on
the psychodynamics of attachment and sexuality. In: Diamond
D, Blatt SJ, Lichtenberg JD, eds. Attachment and sexuality.
New York: The Analytic Press/Taylor & Francis Group;
2007:51–78.
13 Johnson S, Zuccarini D. Integrating sex and attachment
in emotionally focused couple therapy. J Marital Fam Ther
2010;36:431–45.
14 Diamond D, Blatt SJ, Lichtenberg JD. Attachment and sexu-
ality. New York: The Analytic Press/Taylor & Francis Group;
2007.
15 Birnbaum GE. Attachment orientations, sexual functioning,
and relationship satisfaction in a community sample of women.
J Soc Pers Relat 2007;24:21–35.
16 Mulhall J, King R, Glina S, Hvidsten K. Importance of and
satisfaction with sex among men and women worldwide:
Results of the Global Better Sex Survey. J Sex Med 2008;
5:788–95.
17 DeRogatis LR, Burnett AL. The epidemiology of sexual dys-
functions. J Sex Med 2008;5:289–300.
18 Davis D, Shaver PR, Widaman KF, Vernon ML, Follette WC,
Beitz K. “I can’t get no satisfaction”: Insecure attachment,
inhibited sexual communication, and sexual dissatisfaction.
Pers Relatsh 2006;13:465–83.
19 Costa RM, Brody S. Anxious and avoidant attachment, vibra-
tor use, anal sex, and impaired vaginal orgasm. J Sex Med
2011;8:2493–500.
20 Cohen DL, Belsky J. Avoidant romantic attachment and
female orgasm: Testing an emotion-regulation hypothesis.
Attach Hum Dev 2008;10:1–10.
21 Granot M, Zisman-Ilani Y, Ram E, Goldstick O, Yovell Y.
Characteristics of attachment style in women with dyspareu-
nia. J Sex Marital Ther 2011;37:1–16.
22 Stephenson KR, Meston CM. When are sexual difficulties
distressing for women? The selective protective value of inti-
mate relationships. J Sex Med 2010;7:3683–94.
23 Stephenson KR, Meston CM. The association between sexual
costs and sexual satisfaction in women: An exploration of the
Interpersonal Exchange Model of Sexual Satisfaction. Can J
Hum Sex 2011;20:31–40.
24 Birnbaum GE, Reis HT, Mikulincer M, Gillath O, Orpaz A.
When sex is more than just sex: Attachment orientations,
sexual experience, and relationship quality. J Pers Soc Psychol
2006;91:929–43.
25 Bogaert AF, Sadava S. Adult attachment and sexual behavior.
Pers Relatsh 2002;9:191–204.
26 Brassard A, Shaver PR, Lussier Y. Attachment, sexual experi-
ence, and sexual pressure in romantic relationships: A dyadic
approach. Pers Relatsh 2007;14:475–93.
27 Davis D, Shaver PR, Vernon ML. Attachment style and sub-
jective motivations for sex. Pers Soc Psychol Bull 2004;30:
1076–90.
28 Impett EA, Gordon AM, Strachman A. Attachment and daily
sexual goals: A study of dating couples. Pers Relatsh 2008;
15:375–90.
29 Little KC, McNulty JK, Russell VM. Sex buffers intimates
against the negative implications of attachment insecurity. Pers
Soc Psychol Bull 2010;36:484–98.
30 Schachner DA, Shaver PR. Attachment dimensions and sexual
motives. Pers Relatsh 2004;11:179–95.
31 Mikulincer M, Florian V, Tolmacz R. Attachment styles and
fear of personal death: A case study of affect regulation. J Pers
Soc Psychol 1990;58:273–80.
Review Adult Attachment and Sexual Functioning
32 Simpson JA. Influence of attachment styles on romantic rela-
tionships. J Pers Soc Psychol 1990;59:971–80.
33 Cooper ML, Shapiro CM, Powers AM. Motivations for sex
and risky sexual behavior among adolescents and young adults:
A functional perspective. J Pers Soc Psychol 1998;75:1528–58.
34 Hazan C, Shaver P. Romantic love conceptualized as an
attachment process. J Pers Soc Psychol 1987;52:511–24.
35 Wei M, Russell DW, Mallinckrodt B, Vogel DL. The
Experiences in Close Relationship Scale (ECR)-short form:
Reliability, validity, and factor structure. J Pers Assess 2007;
88:187–204.
9
36 Brassard A, Lussier Y, Shaver PR. Attachment, perceived
conflict, and couple satisfaction: Test of a mediational dyadic
model. Fam Relat 2009;58:634–46.
37 Stone AA, Turkkan JS, Bachrach CA, Jobe JB, Kurtzman HS,
Cain VS. The science of self-report: Implications for research
and practice. Mahwah, NJ: Lawrence Erlbaum Associates Pub-
lishers; 2000.
38 Brennan KA, Clark CL, Shaver PR. Self-report measurement
of adult attachment: An integrative overview. In: Simpson JA,
Rholes WS, eds. Attachment theory and close relationships.
New York: Guilford Press; 1998:46–76.
J Sex Med **;**:**–**