Journal of Couple & Relationship Therapy

Innovations in Clinical and Educational Interventions

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Examining Gender in Heterosexual Couple

Relationships Utilizing the Biobehavioral Family
Model: Implications for Couple Therapy

Candice A. Maier, Armeda Stevenson Wojciak & Christi R. McGeorge

To cite this article: Candice A. Maier, Armeda Stevenson Wojciak & Christi R. McGeorge
(2021): Examining Gender in Heterosexual Couple Relationships Utilizing the Biobehavioral
Family Model: Implications for Couple Therapy, Journal of Couple & Relationship Therapy, DOI:
10.1080/15332691.2021.1900010

To link to this article: https://doi.org/10.1080/15332691.2021.1900010

Published online: 26 Mar 2021.

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JOURNAL OF COUPLE & RELATIONSHIP THERAPY
https://doi.org/10.1080/15332691.2021.1900010

Examining Gender in Heterosexual Couple

Relationships Utilizing the Biobehavioral Family Model:
Implications for Couple Therapy
Candice A. Maiera, Armeda Stevenson Wojciakb, and Christi R. McGeorgec
a
University of Wisconsin-Stout, Menomonie, WI, USA; bUniversity of Minnesota, Minneapolia,
Minnesota, USA; cNorth Dakota State University, Fargo, North Dakota, USA

ABSTRACT KEYWORDS
This feminist-informed study examined the ability of the Couples therapy; feminist
Biobehavioral Family Model (BBFM; Wood, 1993) to explain family therapy; mental
connections between heterosexual couple processes, health, health; physical health
and the influence of gender attitudes and beliefs. The sample
consisted of 595 adults in romantic relationships. Results dem-
onstrated some support for the BBFM in explaining health
quality. Romantic partner emotional climate was positively
associated with biobehavioral reactivity, and gender attitudes
and beliefs were significantly associated with biobehavioral
reactivity and disease activity. Applying the BBFM and incor-
porating gender through a feminist lens demonstrates ways
by which couple processes affect individuals’ health, which
has significant implications for couple therapy.

There is emerging evidence that couples-based therapeutic interventions

yield positive benefits for couples experiencing chronic illness (Kowal et al.,
2003; Martire, 2013; Novak, 2019; Tankha et al., 2020). A contributing fac-
tor to poor health outcomes may be relationship distress, as relationship
distress – particularly conflict – is strongly linked to psychological and
physical health problems (Kamp Dush et al., 2008; Kiecolt-Glaser &
Newton, 2001; Kiecolt-Glaser & Wilson, 2017). The impact of relational
distress on partner’s psychological and physical health appears to vary
based on gender (Kiecolt-Glaser & Newton, 2001; Maier & Priest, 2016;
Monin & Clark, 2011; Roberson et al., 2021). Given the efficacy of couple
therapy in treating relationship distress (Lebow et al., 2012; Snyder et al.,
2006), it is critical for couple therapists to further understand the connec-
tion between physical and psychological health and relational dynamics. In
particular, this article seeks to explore the impact of gender attitudes and
beliefs on the mental and physical health of partners in heterosexual

CONTACT Candice A. Maier maierc@uwstout.edu University of Wisconsin-Stout, 415 10th Avenue E,

Heritage Hall 142, Menomonie, WI 54751, USA.
ß 2021 Taylor & Francis Group, LLC
2 C. A. MAIER ET AL.

romantic relationships by expanding on the Biobehavioral Family Model

(BBFM; Wood, 1993).
A growing body of research has linked the mental and physical health of
adults to relationship quality with romantic partners (Carr & Springer,
2010; Overbeek et al., 2006; Ridgeway & Correll, 2004). Specifically, close
relationships can impact risk factors related to health in both positive and
negative ways. For instance, research shows that poor marital quality affects
health trajectories over time (Proulx & Snyder, 2009) and can contribute to
exacerbated mental health symptoms such as depression and anxiety
(Whisman, 2007). Greater marital quality, in contrast, has been shown to
help ameliorate mental and physical health symptoms and lead to higher
life quality (Robles et al., 2014; Slatcher & Selcuk, 2017; Umberson et al.,
2006). It is important for couple therapists to consider the connection
between health and relational quality in order to more effectively meet the
needs of their clients.
Further, although heterosexual marriage, in particular, has potential
advantages for both partners, couple therapists need to be aware of the
research that finds men generally derive more health benefits from mar-
riage (Horwitz et al., 1996; Kiecolt-Glaser & Newton, 2001; Wanic & Kulik,
2011) and live longer than never-married, divorced, and widowed men
(Harvard Health Publishing, 2010). Although a portion of the existing
research on martial quality suggests only minor gender differences in mari-
tal satisfaction (Amato et al., 2003; Jackson et al., 2014) and similar health
trajectories for men and women (Rogers & Amato, 2000), other studies
have found that wives’ reports of marital quality are significantly lower
compared to husbands’ (Kamp Dush et al., 2008; Myers & Booth, 1999;
Stevenson & Wolfers, 2009). One possible explanation for this finding is
that women are often socialized by a patriarchal society to be the emotional
and physical caretakers in relationships, and that married heterosexual men
are, in many ways, not asked to carry the emotional and physical work of
relationships (Enns, 2004). These gender and power disparities often lead
to relational distress (Keeling, 2008) and can have a profound impact on
the effectiveness of couple therapy and need to be carefully considered by
therapists who work with heterosexual couples (Haddock & Lyness, 2002;
Jonathan & Knudson-Martin, 2012; Maier & Priest, 2016; McGeorge et al.,
2009; 2013).
Given that health and well-being are important components to effective
couple therapy, there is a need to contextualize health within the context of
gender in order to consider the gap between women’s and men’s mental
and physical health. Therefore, this study sought to explore the extent to
which the Biobehavioral Family Model (BBFM; Wood, 1993) could provide
important insights for clinicians. The BBFM theorizes that there is a
 JOURNAL OF COUPLE & RELATIONSHIP THERAPY 3

Romantic Partner Disease

Emotional Activity
Climate
(DA)
(RPEC)

Biobehavioral
Reactivity
(BBR)

Gender
Attitudes and
Beliefs

Figure 1. The Biobehavioral Family Model as modified for the focus of this study (Wood, 1993)
with hypothesized model incorporating gender attitudes and beliefs.

reciprocal, mutual influence between social, emotional, and physical factors

on facets of illness and health, and posits that close relationships play a
critical role in overall health outcomes (Wood & Miller, 2002). The model
further posits that proximity, relationship quality, and interpersonal respon-
siveness are all part of the larger family emotional climate—or in this
study’s case, the romantic partner emotional climate. For this study, biobe-
havioral reactivity is the pivotal link in the BBFM that connects romantic
partner emotional climate with the presence of disease, which is typically
measured as disease-related physiological processes (Wood & Miller, 2002;
see Figure 1 for a visual of the model and this study’s hypothesized links).
Thus, by exploring the relationship between health, gender, and romantic
partner emotional quality, we hope to provide couple therapists with
insights into how to better serve heterosexual couples.

Theoretical framework
A feminist framework was used to inform every aspect of this study with
the intent of exploring the relationships between mental health, physical
health, and gender attitudes and beliefs using the BBFM. Although there
are many schools of feminism, a definition by hooks (2000) was used to
guide this study, namely, feminism is, “a movement to end sexism, sexist
exploitation, and oppression” (p. 1). In order to expand on this definition
of feminism, two primary tenets were used to further guide this study: (a)
both women and men are constrained by gender norms, which often define
and limit attitudes and behaviors in romantic relationships; and (b) women
4 C. A. MAIER ET AL.

are oppressed by powerful socializing forces, which construct the way soci-
ety views couple relationships and women’s role within the relational con-
text (Baber, 2009; Baber & Allen, 1992; hooks, 2000).
The feminist framework for this study is also based on the notion that
women and men make daily decisions in the context of their relationship
that are affected by the actual and perceived options that are available to
them (Baber, 2009; Baber & Allen, 1992). In this study, gender attitudes
and beliefs were conceptualized in terms of the extent to which women
and men interact according to traditional gender socialization scripts within
their romantic relationship (Enns, 2004). Finally, a feminist perspective
invites a critique of the roles that women and men perform based on
socially constructed gender norms as well as a critique of the ways in which
women and men are perceived in society (Baber, 2009; Enns, 2004;
hooks, 2000).

Literature review
Gender, couples, and health
Given that health and well-being are important components within the
BBFM, a brief review of the current literature on the intersection of gender,
health, and couple relationships is provided. The National Institutes of
Health’s (NIH) Strategic Plan for Women’s Health Research (2019) high-
lighted a strong link between gender imbalances in differential disease risk
and effects on women’s health (Ridgeway & Correll, 2004). Additionally,
women are nearly twice as likely than men to experience chronic mental
illness, such as depression and anxiety (National Institutes of Health, 2019)
and report additional risk factors for physical health outcomes, including
coronary heart disease (National Institutes of Health, 2019) and heart
attacks compared to men (Mosca et al., 2011). Further, research has docu-
mented differences in physiological stress response systems for men and
women, suggesting that women may experience higher cortisol output and
greater reactivity to social and relational stressors than men (Berg &
Woods, 2009; Laurent et al., 2013; Rodriguez & Margolin, 2013). From a
feminist perspective, these findings highlight the impact of the documented
inequalities that are present in heterosexual relationships that appear to
influence physiological health (Kiecolt-Glaser & Newton, 2001; Maier &
Priest, 2016; Monin & Clark, 2011; Roberson et al., 2021; Wanic &
Kulik, 2011).
Moreover, a growing body of research suggests that those who report
poor relationship quality are, for example, more likely to meet diagnostic
criteria for anxiety and depressive disorders (Overbeek et al., 2006;
Whisman, 2007), and be more likely to experience early onset hypertension
 JOURNAL OF COUPLE & RELATIONSHIP THERAPY 5

(Proulx & Snyder, 2009). Further, romantic relationships can serve as a

protective mechanism against disease and illness, especially when relation-
ships are built around a sense of support and cohesion (Wood & Miller,
2002). Thus, the emotional processes and relationship quality within close
romantic relationships are crucial to understanding health, in part because
these relationships can influence overall mental and physical health (Weihs
et al., 2002).

Gender socialization from a feminist perspective

Feminist scholars have long argued the importance of gender as a central
organizing principle of family life (Enns, 2004). For example, given the
high prevalence rates of intimate partner violence (Smith et al., 2015) and
the emotional and physical strain related to caregiving, which both dispro-
portionately affect women (Berg & Woods, 2009), it is no surprise that
women often experience disadvantages in romantic relationships. Gender
socialization from a feminist perspective suggests that women and men are
both constrained by gender norms in relationships, which often limit and
define what constitutes as acceptable behaviors for them within familial
and societal systems (Baber & Allen, 1992). Researchers argue that these
gender role constraints (e.g., gender attitudes and beliefs), as shaped by
context and culture, play a significant role in relationship satisfaction
(McGeorge et al., 2009). Gender role constraints may affect not only rela-
tionship satisfaction, but eventual health outcomes and thus, need to be
considered in the larger BBFM, which historically and currently have not
been included as a part of the model.

Study aims and hypotheses

The purpose of this study was to expand the BBFM by considering the
impact of gender attitudes and beliefs on the mental health and physical
health of individuals in heterosexual romantic relationships and the influ-
ence of these findings on couple therapy. The BBFM posits that the pivotal
construct linking romantic partner emotional climates to mental and phys-
ical health outcomes is biobehavioral reactivity, which reflect an individu-
al’s ability to manage and regulate emotion (Wood et al., 2000). The
construct that has not been considered in previous research is the degree to
which gender attitudes and beliefs impact one’s ability to regulate emotion
and thus, impact the emotional climate of the couple relationship as well as
mental and physical health outcomes, which reflect important considera-
tions for therapists.
6 C. A. MAIER ET AL.

Specifically, this study tested the inclusion of gender attitudes and beliefs
as they relate to romantic relationships as a distinct variable in the BBFM.
The feminist framework that guides this study argues that gender attitudes
and beliefs affect not only relationship satisfaction, but eventual health out-
comes and thus, needs to be considered in the larger BBFM and by clini-
cians working with heterosexual couples. Additionally, this study sought to
address the gaps in the literature regarding empirically tested links between
couple relationships, gender, and health. Exploring gender attitudes and
beliefs related to couple relationships provide additional understandings of
how perceptions related to gender within heterosexual romantic relation-
ships affect mental and physical health. Thus, the following research ques-
tions were asked: How do gender attitudes and beliefs impact the
Biobehavioral Family Model (BBFM)? Specifically, how do gender attitudes
and beliefs impact romantic partner emotional climate (RPEC), how do
gender attitudes and beliefs impact biobehavioral reactivity (BBR), and
finally, how do gender attitudes and beliefs impact disease activity (DA)?

Method
Participant recruitment and description
To be included in the study, participants had to be living together or be mar-
ried for at least two years in a heterosexual relationship. The 2-year require-
ment stems from a study conducted by Overbeek et al. (2006) and colleagues
demonstrating that marital quality is best assessed for depression and anxiety
symptoms at a 2-year follow-up. Participants were recruited through two
Midwestern university email listservs and social media posts. The sample
included 595 adult participants in committed romantic relationships. Overall,
the sample was largely White, college-educated women in the 22–34
(SD ¼ 1.8) age range who were married and living (not married) with their
partners. Participants included 76.3% women (n ¼ 454) and 23.5% men
(n ¼ 140); one individual (n ¼ 1) identified as transgender (0.2%). Moreover,
participants ranged in age from 18 to 65 years and older with a mean age of
38.2 years (SD ¼ 1.3), and a majority reported a household income of $80,000
or above (59.7%). Participants most often reported their highest level of educa-
tion as postgraduate (24.5% with a master’s degree and 31.9% with a doctoral
or professional degree), with 28.1% holding a bachelor’s degree.

Measures
Gender attitudes and beliefs
Gender attitudes and beliefs were measured using the Gender Roles Beliefs
Scale (GRBS; Kerr & Holden, 1996), which assessed attitudes and beliefs
 JOURNAL OF COUPLE & RELATIONSHIP THERAPY 7

Table 1. Descriptive statistics of gender role beliefs scale (N ¼ 595).

Scale items M SD Min. Max. N
Swearing disrespectfula 2.38 1.21 1 5 594
Men should take initiativea 2.27 1.08 1 5 593
Women no sexual freedomb 2.54 0.82 1 5 594
Women work inside home 1.58 0.91 1 5 593
Husband legal representative 1.36 0.73 1 5 593
Men pay dinner check 1.67 0.90 1 5 593
Men show courtesya 3.63 1.07 1 5 594
Women childrearing/housea 1.39 0.74 1 5 593
Swearing worse for women 1.91 1.11 1 5 593
Note. Higher total scores indicate more less prescriptive ideas regarding gender role ideology. Range 1–5.
Note. The symbol (a) designates items were reverse coded.
Note. The symbol (b) designates items were removed.

about how gender functions in relationships. This 9-item measure demonstrated

strong internal consistency and test–retest reliability (Kerr & Holden, 1996).
Participants responded to items using the scale’s 7-point Likert scale (“Strongly
agree” to “Strongly disagree”). Sample items include, “Women should be con-
cerned with their duties of childbearing and house tending, rather than with the
desires for professional and business careers,” “Women should have as much sex-
ual freedom as men,” and “The husband should be regarded as the legal repre-
sentative of the family group in all matters of law.” Higher total scores indicate
more “feminist responding” (Kerr & Holden, 1996) or progressive attitudes and
less prescriptive ideas regarding gender role ideology and distinction. In the final
analysis, four items were removed to improve model fit (see Table 1). Cronbach
alpha internal consistency was 0.75.

Romantic partner emotional climate

Participants completed the Couples Satisfaction Index (CSI; Funk & Rogge,
2007) to assess the emotional climate of their relationship. This 32-item
measure includes items rated on a 6-point Likert scale (“Not at all true” to
“Completely true;” “Extremely unhappy” to “Perfect;” “Always agree” to
“Always disagree;” “All of the time” to “Never;” “Worse than all others;” to
“Better than all others;” and “Never” to “More often”) and includes state-
ments and questions like, “I still feel a strong connection with my partner,”
“I feel I can confide in my partner about virtually anything,” and “How
well does your partner meet your needs?” Three items (shown in Table 1)
were recoded to reflect similar directionality and two items were excluded
from the final analysis due to poor model fit (see Table 2). Higher scores
represent higher satisfaction. Cronbach alpha internal consistency was 0.96.

Biobehavioral reactivity
Biobehavioral reactivity was measured using the Center for Epidemiologic
Studies Depression Scale (CES-D; Radloff, 1977). This short self-report
8 C. A. MAIER ET AL.

Table 2. Descriptive statistics of couple satisfaction index (N ¼ 595).

Index items M SD Min. Max. N
Degree of happinessa 5.02 1.26 1 7 594
Time spent togethera 4.62 0.83 1 6 595
Making decisions 4.73 0.73 2 6 594
Affection 4.50 0.98 1 6 593
Going well overall 4.79 0.76 2 6 595
Regret relationshipb 5.23 0.93 1 6 595
Feel a strong connection 5.18 1.11 1 6 595
Would marry again 5.03 1.34 1 6 594
Our relationship is strong 5.12 1.18 1 6 594
Wonder if there is someone elseb 5.01 1.35 1 6 593
Relationship makes me happy 4.99 1.16 1 6 595
Cannot imagine life w/o 5.13 1.33 1 6 595
Warm and comfortable 5.11 1.23 1 6 595
Can confide 4.94 1.31 1 6 595
Second thoughtsb 5.17 1.38 1 6 594
Romance 4.23 1.45 1 6 593
Part of a team 4.90 1.35 1 6 592
Cannot imagine another 4.49 1.56 1 6 593
Rewarding 4.75 1.13 1 6 594
Meet needs 4.51 1.05 1 6 595
Met expectations 4.55 1.25 1 6 593
Overall satisfaction 4.87 1.14 1 6 595
Good compared to others 4.95 0.94 2 6 594
Enjoy company 5.52 0.86 2 6 595
Fun together 4.78 1.19 1 6 595
Note. Higher mean scores represent higher relationship satisfaction. Range 1–6 for questions 2–24. Range 1–7
for question 1.
Note. The symbol (a) designates items were reverse coded.
Note. The symbol (b) designates items were removed.

scale is designed to measure depressive symptoms for the general popula-

tion (Radloff, 1977). The 20-item scale used for this study asked partici-
pants to identify the number of days using an 8-point scale (0 ¼ None,
7 ¼ Seven days per week) during the past week they encountered the fol-
lowing: “feel bothered by things that usually don’t bother you,” “not feel
like eating,” “feel that you could not shake off the blues even with help
from your family and friends,” “having trouble keeping your mind on what
you were doing,” “feel depressed,” “feel that everything you did was an
effort,” “feel fearful,” “slept restlessly,” “talk less than usual,” “feel lonely,”
“feel sad,” and “feel like you could not get going.” Three items were
excluded from final analysis due to poor model fit (see Table 3). All items
were added together and higher scores reflected a higher level of depres-
sion. Cronbach alpha internal consistency was 0.92.

Disease activity
To assess the impact of romantic relationships and emotion dysregulation
on the physical health of participants, two self-report questions were used.
The first question asked participants to rate their general health status
using a Likert scale (1 ¼ Excellent, 2 ¼ Very Good, 3 ¼ Good, 4 ¼ Fair, and
5 ¼ Poor). The second question asked participants to rate their general
 JOURNAL OF COUPLE & RELATIONSHIP THERAPY 9

Table 3. Descriptive statistics of center for epidemiologic studies depression scale and health
scale (N ¼ 595).
Scale items M SD Min. Max. N
Bothereda 2.24 0.91 1 4 592
Poor appetitea 1.18 0.50 1 4 593
Could not shake off blues 1.39 0.75 1 4 595
Felt just as good as othersb 1.59 0.89 1 4 593
Trouble keeping mind on task 1.87 0.90 1 4 594
Felt depressed 1.42 0.75 1 4 594
Everything was an effort 1.64 0.85 1 4 592
Felt hopefulb 1.65 0.86 1 4 594
Thought life had been a failure 1.18 0.55 1 4 595
Felt fearful 1.32 0.64 1 4 593
Sleep restless 1.90 0.94 1 4 595
Felt happyb 1.54 0.72 1 4 594
Talked less than usual 1.43 0.72 1 4 595
Felt lonely 1.42 0.78 1 4 593
People were unfriendly 1.27 0.56 1 4 595
Enjoyed lifeb 1.56 0.72 1 4 595
Had crying spells 1.23 0.56 1 4 593
Felt sad 1.50 0.69 1 4 594
Felt people disliked me 1.32 0.64 1 4 594
Could not get goinga 1.57 0.83 1 4 594
Current healthc 2.32 0.86 1 5 594
Health one year agoc 2.68 0.84 1 5 595
Note. Higher total scores indicated higher symptomology. Lower means indicate fewer depressive symptoms.
Range 1–4.
Note. The symbol (a) designates items were reverse coded.
Note. The symbol (b) designates items were removed.
Note. The symbol (c) designates item from the Health Scare. Lower means on these items indicated higher self-
rated health. Range 1–5.

health now compared to one year ago using a similar scale (1 ¼ Much bet-
ter now than one year ago, 2 ¼ Somewhat better now than one year ago,
3 ¼ About the same, 4 ¼ Somewhat worse now than one year ago, and
5 ¼ Much worse now than one year ago). The two self-report questions
were summed to create the construct disease activity that was used in the
confirmatory factor analysis. Although this construct was not measured
using an existing health survey, efficacy research on self-reported health
care visits has shown that these reports are significantly positively corre-
lated to patient medical records (Crane & Christenson, 2012). In other
words, individual self-reports on their own health tend to be quite accurate.
These items were scored so that lower scores demonstrate perception of
better overall health status.

Analytic strategy
First, data were exported from the online survey software, Qualtrics, and
downloaded to IBM Statistical Package for the Social Sciences (SPSS)
Version 23.0. Data from 888 participants were then cleaned and all varia-
bles were screened for missing data and recoded to accommodate variations
in the data and determine agreement in scale item values. Regarding data
10 C. A. MAIER ET AL.

Table 4. Means, standard deviations, ranges, and alpha coefficients for study meas-
ures (N ¼ 595).
Variables M SD Range a (# of items) n
CSI 4.34 0.79 1–6 0.96(22) 578
GRB 2.29 0.56 1–5 0.75(5) 590
CES-D 1.87 0.29 1–4 0.91(17) 579
Health Questions 2.50 0.65 1–5 0.32(2) 594
Note. CSI ¼ Couple satisfaction index; GAB ¼ Gender attitudes and belief scale; CES-D ¼ Center for epidemiologic
studies depression scale.

screening, individuals who responded “no” to the first question (i.e., Are
you currently living together or married to your romantic partner for at
least 2 years?) were not included in the final analysis. The total number of
individuals who clicked on the email survey link but selected “no” to this
question was 108. Next, all individuals who responded “yes” to the first
question, but who did not respond to any of the survey questions beyond
the first question were deleted from the database (n ¼ 81). Lastly, individu-
als who responded to some questions (range 2–6 items), but who did not
continue onto the next and subsequent surveys were also deleted from the
database (n ¼ 104), resulting in a total sample of 595 participants.
Second, descriptive statistics on age, gender, education status, marital sta-
tus, and income were run on the final sample of 595 individuals. T tests
were also run comparing gender on all four measures. In addition, correla-
tions and Cronbach alphas were run to assess for internal consistency on
the measure items for romantic partner emotional climate, gender attitudes
and beliefs, biobehavioral reactivity, and disease activity.
Third, using Mplus 7 (Muthen & Muthen, 2012), confirmatory factor
analysis (CFA) was utilized to determine the validity of the measures for
gender attitudes and beliefs, romantic partner emotional climate, biobeha-
vioral reactivity, and disease activity. The fourth and final step in the ana-
lysis was structural equation modeling (SEM) to test associations between
gender attitudes and beliefs, romantic partner emotional climate, biobeha-
vioral reactivity, and disease activity. Goodness-of-model-fit indices were
used to test the model with the sample: Comparative Fit Index (CFI),
Tucker–Lewis Index (TLI), and Root Mean Square Error of Approximation
(RMSEA). Missing data was accounted for using the maximum likelihood
with robust standard errors (MLR); see Figure 1 for hypothesized model.

Results
Correlations and descriptive statistics for all study variables are shown in
Tables 1–3. Means, standard deviations, ranges, and alpha coefficients for
all study measures are shown in Table 4. Bivariate Pearson correlations are
shown in Table 5. All significant correlations were in the expected
 JOURNAL OF COUPLE & RELATIONSHIP THERAPY 11

Table 5. Bivariate Pearson correlations of study variables (N ¼ 595).

Variables 1 2 3 4
1. Physical health –
2. CSI .19 –
3. GAB .04 –.09 –
4. CES-D .32 –.46 .028 –
Note. CSI ¼ Couple satisfaction index; GAB ¼ Gender attitudes and belief scale; CES-D ¼ Center for Epidemiologic
Studies Depression Scale.
p<.10. *p<.05. **p<.01. (two-tailed).

Table 6. T test results comparing gender and age on romantic partner emotional climate, gen-
der attitudes and beliefs, biobehavioral reactivity, and disease activity.
Variable Male Female T
Gender
RPEC 4.25 4.35 –.898
GAB 2.00 1.75 3.91
BBR 1.92 1.90 .365
DA 5.05 4.97 .585
Note. RPEC ¼ Romantic partner emotional climate; GAB ¼ Gender attitudes and beliefs; BBR ¼ Biobehavioral
reactivity; DA ¼ Disease activity.
p<.10. *p<.05. **p<.01.

direction. Physical health was significantly correlated with all other varia-
bles with the exception of gender attitudes and beliefs. Romantic partner
emotional climate (CSI) was significantly correlated with gender attitudes
and beliefs (GRBS) and disease activity. Moreover, independent sample t
tests were conducted that examined how participants varied on the study
variables based on their gender, which was found to be significant
(t ¼ 3.91, p .05). Specifically, men tended to endorse slightly less progres-
sive attitudes related to gender role ideology and stereotypes (see Table 6).

Confirmatory factor analysis

Confirmatory factor analyses (CFAs) were run on all constructs. The first
CFA focusing on gender attitudes and beliefs demonstrated poor fit
v2 ¼ 838.363, p¼.000, SRMR¼.051, CFI¼.879, TLI¼.838, RMSEA¼.149.
Specifically, although the SRMR fit statistic fell within a good fitting model,
the other statistics (i.e., CFI, TLI, and RMSEA) all demonstrated poor fit.
After examination of the factor loadings, one item (i.e., “The initiative
should usually come from the man”) was removed and analyses were run
again, yielding slightly better fit statistics v2 ¼ 783.412, p¼.000,
SRMR¼.047, CFI¼.896, TLI¼.855, RMSEA¼.081. For this model, the CFI
and TLI are higher, and the SRMR and RMSEA are lower. However, the
CFI, TLI, and RMSEA still fell out of range of what would be considered a
good model fit. After another examination of the factor loadings, a third
model was tested that consisted of the unique items of gender attitudes and
beliefs, which yielded a vastly improved model fit v2 ¼ 443.95, p¼.000,
12 C. A. MAIER ET AL.

SRMR¼.01, CFI ¼ 1.000, TLI ¼ 1.003, RMSEA¼.000. For this model, all
fit statistics fell into appropriate ranges to be considered a good fitting
model. Items removed from analysis are noted with a letter superscript (b)
in Table 1.
The second CFA focused on romantic partner emotional climate initially
demonstrated poor fit v2 ¼ 6578.58, p¼.000, SRMR¼.071, CFI¼.870,
TLI¼.858, RMSEA¼.127. Again, although the SRMR fit statistic fell within
a good fitting model and the TLI was closer to 0.95 than the previous
CFA, the other statistics demonstrated poor fit. However, after removal of
two items that were not loading well onto the model (i.e., “Indicate degree
of happiness in relationship,” and “Amount of time spent together”), the
model demonstrated greatly improved fit v2 ¼ 9547.560, p¼.000,
SRMR¼.032, CFI¼.952, TLI¼.948, RMSEA¼.057. Items removed from
analysis are noted with a letter superscript (b) in Table 2. The items
removed from the both the first and second CFA are from the CSI.
Although this study used the longest version of the CSI (32-items), Funk
and Rogge (2007) recommend that one of the shorter versions (i.e., 8- or
16-item) is used in larger studies that are not concerned about statistical
power. Given that we were initially concerned with power, we chose to use
the longest version of the CSI; however, given our unexpected high number
of participants, the removal of these items created less noise (i.e., higher
precision of measurement) and yielded ultimately an increase in statis-
tical power.
The third CFA focused on biobehavioral reactivity demonstrated mixed
fit v2 ¼ 3259.041, p¼.000, SRMR¼.064, CFI¼.815, TLI¼.793,
RMSEA¼.081. Although the RMSEA demonstrated appropriate fit statistics
of less than 1, the CFI and TLI demonstrated poor fit. After examination
of the model results and estimates, two items were removed (i.e., “I was
bothered by things that usually bother me,” and “I did not feel like eating”)
and the CFA was run again. This analysis yielded slightly better fit statistics
v2 ¼ 2763.470, p¼.000, SRMR¼.046, CFI¼.898, TLI¼.888, RMSEA¼.064,
yet still demonstrated overall poor fit. Specifically, the CFI and TLI were
both less than 0.95 and the RMSEA was greater than 0.05. A final model
was run to improve model fit by removing a third item (i.e., “I could not
get ‘going’”), resulting in an improved model fit, which was used in the
final analysis and full model v2 ¼ 1883.40, p¼.000, SRMR¼.047, CFI¼.91,
TLI¼.89, RMSEA¼.05. Items removed from analysis are noted with a letter
superscript (b) in Table 3. The need to remove the two items from CES-D
from this third CFA analysis might be explained by a potential gender
biases in these items (Carleton et al., 2013). It is possible there was inflation
of both women’s and men’s CES-D scores due to cultural norms regarding
“appropriate” emotional expression. Thus, we suggest future research
 JOURNAL OF COUPLE & RELATIONSHIP THERAPY 13

studies employing the 20-item version of the CES-D to be mindful of the

ways traditional gender socialization might impact participants’ responses
to this self-report measure, and thus be cautious when interpreting results.
The final CFA was conducted using two self-report questions asking par-
ticipants about disease activity. This model demonstrated good fit
v2 ¼ 30.850, p¼.000, SRMR¼.000, CFI¼.966, TLI¼.1.034, RMSEA¼.000.
Specifically, the SRMR, CFI, TLI, and RMSEA fit statistics all indicated
good fit, with a CFI and TLI greater than 0.95, a RMSEA less than 0.05,
and a SRMR values less than 1.00.

Structural model
Goodness-of-fit indices for the model indicated the proposed model fit the
data (v2 ¼ 15551.01, p¼.000, SRMR¼.057, CFI¼.920, TLI¼.916,
RMSEA¼.043, 90% CI¼.041, .046). Pathways between variables of romantic
partner emotional climate, gender attitudes and beliefs, biobehavioral
reactivity, and disease activity were significant. More specifically, the higher
satisfaction participants reported in their committed relationships (i.e., the
more positive relationship dynamics they experienced), the less biobehavio-
ral reactivity (i.e., depression) they experienced. In other words, the happier
individuals reported their relationship was, the fewer depressive symptoms
they reported. In addition, the more progressive participants were in their
gender attitudes and beliefs, the less biobehavioral reactivity and better
physical health (i.e., disease activity) they reported. Pathways between
romantic partner emotional climate and disease activity, and biobehavioral
reactivity and disease activity were nonsignificant (see Figure 2).
Although romantic partner emotional climate and biobehavioral reactiv-
ity were not directly linked to disease activity, goodness-of-fit statistics
were good for all constructs used in the study. In addition, correlation find-
ings suggested romantic partner emotional climate was significantly associ-
ated with the measure of disease activity, gender attitudes and beliefs were
significantly associated with romantic partner emotional climate, and biobe-
havioral reactivity was significantly associated with both disease activity
and romantic partner emotional climate (see Table 5).

Discussion
The results from this study indicate that by adding gender attitudes and
beliefs to the BBFM, the model is able to explain some of the mental and
physical health outcomes for adults in committed heterosexual relationships
and thus, has important implications for couple therapy. Self-reports of
couple relationship functioning, including romantic partner emotional
14 C. A. MAIER ET AL.

Figure 2. BBFM (N ¼ 595) with Romantic Partner Emotional Climate, Gender Attitudes and
Beliefs, Biobehavioral Reactivity as mediating variable, and Disease Activity p<.05, p<.01,
p<.001 (two-tailed). Significant paths are indicated in bold. v2¼15551.01, p¼.000,
SRMR¼.057, CFI¼.920, TLI¼.916, RMSEA¼.043 (90% CI¼.041, .046).

climate and gender attitudes and beliefs affects partnered adults’ mental
health. In other words, the less problematic (or more positive) adults
viewed their romantic relationship, the less likely they were to report being
depressed, which supports existing literature linking relationship quality
and mental health (Carr & Springer, 2010; Kiecolt-Glaser & Newton, 2001;
Weihs et al., 2002; Whisman, 2007). This finding provides even greater
support for the importance of couple therapy as it suggests that by working
to actively improve their romantic relationship, individuals can also
improve their own mental health. This furthers the argument that has been
made for the reimbursement of couple therapy, which would involve an
expansion of third-party payment beyond individual therapy as a legitimate
treatment for mental health concerns (Clawson et al., 2018; Crane &
Christenson, 2012).
 JOURNAL OF COUPLE & RELATIONSHIP THERAPY 15

Participants’ attitudes toward gender roles and ideology also predicted

their self-reported physical health now and self-reported physical health
compared to one year ago, in addition to their level of depression. These
findings demonstrate not only that the BBFM is valuable in understanding
the effects of romantic partner functioning and gender attitudes and beliefs
on the health of adults in committed romantic relationships, but also the
importance of addressing these beliefs and possible inequalities in couple
therapy through the use of feminist family therapy techniques that can help
promote more equitable gender beliefs (Haddock & Lyness, 2002;
McGeorge et al., 2009; Mirkin & Geib, 1999). Previous research has sug-
gested that assisting heterosexual couples in developing more egalitarian
beliefs is associated with greater martial satisfaction (Fowers, 1991;
Thebaud & Halcomb, 2019; Zimmerman, 2000). The findings of this study
suggest that the advantages of holding more egalitarian beliefs may also
include benefits to physical and psychological health. Although the impact
of gender attitudes and beliefs may seem slight in any one instance, the
consequences accumulated over the life course can result in different out-
comes (i.e., disease activity) for women and men. This study additionally
highlights the relationship between women’s health issues and attitudes and
beliefs about gender, which have long been a central concern to the wom-
en’s movement and among feminist family scholars (Gallant et al., 1997;
Travis & Meltzer, 2008; White et al., 2001). This finding further adds to
the existing literature on links between gender imbalances in differential
disease risk and heterosexual romantic relationship quality (Ridgeway &
Correll, 2004), which strengthens the need to address gender and power in
couple therapy.
Further, it is important to note that romantic partner emotional climate
and biobehavioral reactivity were not directly linked to disease activity.
This finding is inconsistent with the literature (Kiecolt-Glaser & Newton,
2001) and BBFM framework, which theorizes the reciprocal, mutual influ-
ences of social, emotional, and physical factors of illness and health (Wood
& Miller, 2002). Here, it is possible that additional contributors to physical
health (disease activity) played a role and that other factors might also help
to explain self-reported physical health outcomes. Based on this rationale, it
is important to not rule out additional contributors to physical health that
may be unrelated to romantic partner emotional climate and biobehavioral
reactivity (depression) and address these concerns with couples in therapy.
Finally, the sample, on average, reported high relationship satisfaction,
progressive gender attitudes and beliefs, low depression symptoms, and
positive physical health. There are many explanations for these findings.
For instance, it is possible that completing a survey about relationship qual-
ity and health was more appealing to those in relationships with higher
16 C. A. MAIER ET AL.

satisfaction or that individuals with lower relationship satisfaction were not

comfortable (even though the survey was entirely anonymous) admitting
their unhappiness with their relationships. Similarly, it could be that the
survey appealed to those with better mental health or that those who are
experiencing depression did not accurately answer the questions asking
about their mental health given the societal stigma, that sadly, still exists.
Additionally, the sample consisted of many college-educated women and
existing research suggests that college-educated women are more likely to
endorse more progressive beliefs and attitudes about gender (Bobbitt-
Zeher, 2007). Similar to the gender divide in women taking on the bulk of
“health behavioral work” in romantic relationships (e.g., performed activ-
ities to promote health behaviors within a couple relationship; Thomeer
et al., 2015), so too is the gender divide of this study: women were more
likely to participate in a study measuring relationship quality, gender, and
health, which is supported by existing research (Millar & Dillman, 2012)
and aligns with the feminist framework that guides this study.
All of these possibilities for understanding the trends within the sample
should be considered when evaluating the findings of this study; however,
it is important to note that the sample for this study is reflective of many
samples within family science research (Smith, 2008). As this was an initial
exploratory study, it provides new insight into adding attitudes about gen-
der and relationship satisfaction to the BBFM as well as ramifications for
couple therapy. However, as researchers seek to replicate and expand on
the findings of this study, it might be helpful to target a clinical population
in order recruit a sample with higher levels of depression, lower levels of
relationship satisfaction, and lower levels of physical health to see if the
model functions similarly to findings of this study. Nevertheless, it remains
important for systemic couple therapists to address both physical and men-
tal health issues when working with couples.

Limitations and future research

Although this study addressed a number of shortcomings in the literature
related to testing the integrated effects of both mental and physical health
on romantic relationships and provided important insight for couple thera-
pists, there were some limitations. First, although online surveys provide
the benefit of being able to collect from more geographical diverse samples,
there are a number of limitations associated with online data collections,
such as limiting samples for studies to individuals with computer access
and having participants choose not to complete surveys based on mistrust
issues stemming from unfamiliarity with the researchers (Dillman et al.,
2009). Additionally, self-rated relationship satisfaction and health measures
 JOURNAL OF COUPLE & RELATIONSHIP THERAPY 17

were used to collect information from participants. Although efficacy

research on self-reported health care visits has shown that these reports are
significantly positively correlated to patient medical records (Crane &
Christenson, 2012), dependence on participants’ self-reported data is prone
to under- and over-reporting of relationship satisfaction and mental health
symptoms, which can be linked to social desirability as human beings often
want to appear happier or healthier than they actually are. In particular,
gender bias in the CES-D (Radloff, 1977) has been examined, which has
called into question the robustness and suitability of such self-report meas-
ures (Carleton et al., 2013). Finally, the majority of participants in this
study were White, college-educated women. Future research replicating this
study should aim to collect a more racially diverse sample with additional
considerations to recruiting a sample with greater gender and educa-
tion diversity.
With regard to future steps for research, it is important to note that tests
of the BBFM with adults integrating a feminist analysis have yet to use
relational or dyadic data, which limits the understanding of how these
effects occur in a more systemic context. Additionally, it is important to
note the inherent problems with cross-sectional data in mediation analyses;
thus, future research replicating this study should consider utilizing a longi-
tudinal design. A necessary next step in understanding how couple rela-
tionships and gender attitudes and beliefs affect health using the BBFM
would be to collect data from both partners in the couple relationship and
further investigate the model dyadically and within a clinical context over
time. This would clarify how both perspectives of relational processes
mutually affect partners’ biobehavioral reactivity and disease activity while
keeping in mind the important role gender can play in couple relationships
and how these processes can change over time. Future studies could also
look at how utilizing previously established clinical approaches that focus
explicitly on gender, power, and relationship equality impact couples’ rela-
tionship satisfaction and mental and physical health outcomes. Finally,
studies might also consider how these constructs apply to lesbian, gay,
bisexual, transgender and queer relationships.
Additionally, although this was an exploratory study testing the associa-
tions of the BBFM with a new extraneous variable (i.e., gender attitudes
and beliefs), unidentified confounding factors may play a role in the find-
ings. For instance, couples’ religiosity or spirituality identity, number of
children, number of times attending therapy, and number of times previ-
ously married were not controlled in this study. These factors would be
important to include in future research studies. Further, it is a limitation of
this study that data were collected in a cross-sectional design. It is possible
that potential associations found in the analyses occur in opposite
18 C. A. MAIER ET AL.

directions even though the BBFM supports the notion of reciprocal influen-
ces. Future research should test the application of the BBFM longitudinally
to ascertain how romantic partner emotional climate and gender relational
context have causal, long-term effects on mental and physical health of
couples and thus, how these effects impact the process and progress of cou-
ple therapy. Finally, although researchers have tested the BBFM with
diverse racial populations, such as Latino Americans (Priest & Woods,
2015), future research could also consider other demographic factors and
additional contextual variables of adult romantic relationships (e.g., socioe-
conomic status, age, sexual orientation, gender identity, etc.) to better
understand how demographic characteristics of specific populations and
individuals affect the processes of the BBFM and its associations.

Implications for clinical practice

The findings of this study suggest that it is important for clinicians to con-
sider the ways in which gender ideology and stereotypes affect a couple’s
relationship and health and how attending to gendered power issues is a
key aspect to helping couples build mutually supportive intimate relation-
ships (Wells, 2016). It could be helpful for clinicians to utilize existing fem-
inist couple therapy approaches when working with clients (Haddock &
Lyness, 2002; McGeorge et al., 2009; Mirkin & Geib, 1999). Specifically,
therapists may consider using “empowering challenges” with heterosexual
couples to facilitate non-stereotypic gender behavior (Haddock & Lyness,
2002). Therapists also need to be mindful of ways that their own traditional
gender socialization may impact their delivery of feedback to couples, as
well as the therapeutic relationship (Haddock & Lyness, 2002).
Additionally, it is important that therapists, especially new clinicians, feel
supported in integrating practices related to addressing gender-based power
structures and promoting egalitarian relationships and thus, seek out the
needed training and/or supervision to do this work (McGeorge et al.,
2009). Given this study’s findings which demonstrated that more progres-
sive attitudes about gender were linked to lower reports of disease activity
and depression, it seems that addressing gender and power in couple ther-
apy is central to working with heterosexual couples.
It is important to note that the findings of this study are not suggesting
that individuals who ascribe to more traditional ideas of gender attitudes
and beliefs would have poorer health outcomes and this study did not test
differences between men’s self-reported gender attitudes and beliefs and
women’s self-reported gender attitudes and beliefs due to low number of
men in the sample. However, the findings do suggest that couple therapists
need to pay attention to gender attitudes and beliefs in general, especially
 JOURNAL OF COUPLE & RELATIONSHIP THERAPY 19

given the documented research that suggests couples who embrace gender
equality are generally more satisfied in their relationships and report better
mental health outcomes (Claffey & Mickelson, 2009; Fowers, 1991;
Thebaud & Halcomb, 2019; Van Willigen & Drentea, 2001). Thus, clinical
processes guided by feminist-informed theory can be helpful in addressing
gendered power interactions (Wells et al., 2017) and help clinicians to con-
sider the ways they can challenge men and women differently in the thera-
peutic context given their differential access to power within heterosexual
relationships as well as help confront or contextualize stereotypic gender
behavior and beliefs among clients (Haddock & Lyness, 2002).
Although the statistical results from the present study are not causal and
further research to determine the longitudinal nature of the effects of gen-
der attitudes and romantic partner emotional climate on adult heath is
necessary, it may be that intervening therapeutically in couples’ functioning
by assessing gender attitudes and beliefs will provide benefits to clients’
mental and physical health. It has been demonstrated that negative couple
relationships have a stronger influence on health than positive relationships
(Campbell et al., 2005). In other words, couples who report poorer relation-
ship satisfaction are more likely to experience poorer mental and physical
health outcomes. Couple therapy may provide benefits to couples experi-
encing distress and can be tailored to include helping couples explore how
their gender attitudes structure their life together as a couple as well as
addressing ways that gendered bids for emotional connection and attune-
ment impact the relationship (Jonathan & Knudson-Martin, 2012).
Systemic therapists are uniquely situated to provide this type of care (i.e.,
couple relational interventions) informed by the BBFM’s pathways (Wood
et al., 2008) and should be included in healthcare teams in order to offer a
critical systemic understanding of partnered adult health functioning and
ways that gender can structure intimate relationships.

Conclusion
This feminist-informed study sought to add to the existing literature on
gender, health, and heterosexual romantic relationships with the hope of
providing new insight to those who practice couple therapy. Although evi-
dence supporting links between heterosexual romantic relationship quality
and health outcomes have been previously documented, these studies have
failed to consider the ways by which gender attitudes and beliefs may
impact relationship satisfaction and health. This study tested a new path-
way in the Biobehavioral Family Model (Wood, 1993) by adding the add-
itional construct of gender attitudes and beliefs and found some support
for the study’s proposed model. The hope of this study is to provide
20 C. A. MAIER ET AL.

important insight into the ways in which gender attitudes and beliefs con-
tribute to heterosexual couple relationships and individual partners’ health
in an effort to better help therapists address the needs of their clients. The
findings of this study are particularly important as they provide support for
relational therapists to explore an often-hidden element of heterosexual
couple dynamics, the impact of gender attitudes on relationship functioning
and mental and physical health.

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