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August K.J., Kelly C.S., and Markey C.N., Marriage, Romantic Relationships, and Health. In: Howard S. Friedman
(Editor in Chief), Encyclopedia of Mental Health, 2nd edition, Vol 3, Waltham, MA: Academic Press, 2016, pp. 46-52.
Copyright © 2016 Elsevier Inc. unless otherwise stated. All rights reserved.
Marriage, Romantic Relationships, and Health
KJ August, CS Kelly, and CN Markey, Rutgers University, Camden, NJ, USA
r2016 Elsevier Inc. All rights reserved.
Glossary
Behavioral health Refers to behaviors, or actions, that have
consequences for health such as alcohol and tobacco use.
Cohabitation Romantic partners who reside together in a
committed, often monogamous, relationship, without
being legally married.
Companionship Enjoyable interaction and camaraderie
among social network members, such as spouses. This
includes engaging in shared recreation and other activities
for enjoyment.
Dating A relationship between two individuals, in which
they engage in mutual activities together to assess interest in
pursuing a more committed relationship. This type of
relationship may or may not be monogamous between two
individuals.
Divorce The legal dissolution of a marriage; considered a
final end to a marital relationship.
Marriage A legal, social, and often religious institution
that binds two romantic partners ‘until death do they part’
or until separation or divorce is sought.
Same-sex relationship A romantic relationship comprised
of two individuals of the same sex (gender); i.e., two men
who are romantically involved or two women who are
romantically involved.
Separation The event in which spouses choose to live
apart, either temporarily (‘trial separation’) or as a step in
the process to divorce. ‘Legal separation’refers to a formal,
court-sanctioned division of marital property.
Social control Attempts to influence and regulate the
health behavior of another individual.
Social support Provision of care and aid in times of
need. Different types of social support have been
distinguished (e.g., emotional, instrumental, and
informational).
Widowhood The relationship status in which one’s
spouse has died. A widow refers to a woman whose
spouse has died; a widower refers to a man whose spouse
has died.
Introduction
Romantic relationships are typically construed as positive
contributors to individuals’lives. A meaningful relationship
with a significant other may bring companionship, friendship,
love, security, and happiness to an individual’s life. It also may
bring health benefits. Being in a romantic relationship usually
indicates greater social integration, which has been found to
be associated with better health outcomes and longevity
(Berkman and Syme, 1979). In fact, some research suggests
that an absence of significant social relationships, such as ro-
mantic partners, may be as detrimental to health as is smok-
ing, high blood pressure, and obesity (House et al., 1988).
Having a partner also provides access to a larger social network
of family, friends, and other individuals in the community,
who offer benefits in their own right (Musick and Bumpass,
2012). Romantic relationships, however, have unique and
robust effects on health compared to other social network ties.
The contributions of romantic relationships, particularly
marriage, to individuals’health have been reported in terms of
both physical health and psychological well-being. In this
article we focus primarily on physical health (see DePaulo;
deJong and Reis entries for other information about relation-
ships and psychological well-being).
How and Why Are Romantic Relationships and Health
Linked?
In general, there is a high degree of concordance between ro-
mantic partners’health and health behaviors, such that the
health of a husband or wife is strongly associated with his or
her spouse’s health (Falba and Sindelar, 2008;Meyler et al.,
2007). Additionally, relationship functioning has been found
to be associated with cardiovascular, endocrine, and immune
functioning (Rankin-Esquer et al., 2000;Robles and Kiecolt-
Glaser, 2003). Married individuals also have been shown to
have better health experiences than nonmarried individuals in
a number of areas, including pain and pain-related disability,
periodontal disease, rheumatoid arthritis, heart health,
neurological disorders, ulcers, and self-reports of overall health
status (Carels et al., 1998;Coughlin, 1990;Kiecolt-Glaser and
Newton, 2001;Levenstein et al., 1995;Marcenes and Sheiham,
1996;Medalie et al., 1992;Rankin-Esquer et al., 2000;Tucker
et al., 1996;Flor et al., 1989;Zautra et al., 1998). Finally, it has
been well established that people who are married live longer
than those who are not married (Rogers, 1995;Lillard and
Waite, 1995;Lillard and Panis, 1996;Umberson et al., 2010;
Friedman and Martin, 2011).
The positive benefits of romantic relationships are thought
to be attributable to both selection and protection effects (Fu
and Goldman, 1994;Kiecolt-Glaser and Newton, 2001). In
other words, healthier individuals are more likely to find and
maintain relationships, and individuals who are in relation-
ships experience the protective effects they may offer. Ac-
cording to the protection theory, an individual’s physical and
psychological experiences are affected by their relationships.
For example, married individuals have been found to be more
likely to exercise and eat breakfast and less likely to smoke or
drink heavily than unmarried individuals (Joung et al., 1995).
Although this theory posits a causal link between romantic
relationships and health, there is no true way to determine
Encyclopedia of Mental Health, Volume 3 doi:10.1016/B978-0-12-397045-9.00074-446
Author's personal copy
whether romantic relationships cause better health outcomes.
However, by examining these associations using advanced
methodologies that involve following couples across time and
documenting their relationship functioning and health at
various intervals, researchers can become more confident in
the temporal order of such posited effects.
A number of reasons have been offered as to why
romantic relationships contribute to better or worse health. In
addition to feelings of attachment and intimacy, individuals
often feel an increased sense of meaning and purpose in
life that may accompany a romantic relationship (Antonovsky,
1979). These positive emotions, in turn, are related to
many beneficial health effects, including lower disease inci-
dence, less health-related symptoms, and increased longevity
(Pressman and Cohen, 2005). More practical explanations
involve the health advantages of having two incomes such as
better access to health care and less stress (Lerman, 2002),
which, in turn, are associated with lower rates of morbidity
and mortality.
Additional pathways whereby romantic relationships are
related to health involve the specific interactions that partners
engage in with each other. The receipt of social support, as well
its perceived availability, often is cited as a common pathway
by which romantic relationships are associated with health
(Robles and Kiecolt-Glaser, 2003;Seeman and Syme, 1987;
see Uchino, Bowen, and Kent entry). Many different types of
social support (emotional, informational, and instrumental)
have been shown to have unique effects on health (Cohen,
2004). A health-specific type of support that has been found to
be especially important in fostering healthy behaviors among
spouses is health-related social support, or efforts to encourage
individuals’positive health beliefs and health behaviors
(August and Sorkin, 2010;Gallant, 2003;Joung et al., 1995;
Markey et al., 2005;Umberson, 1992).
Not only is receiving social support associated with positive
benefits, but some evidence suggests that providing support
may have benefits as well. Support provision has been found
to be associated with less psychological distress (Cialdini et al.,
1973;Midlarsky, 1991), better health (Schwartz and Sendor,
2000), and greater longevity (Brown et al., 2003). Support
provision is not always positive, however, as illustrated by the
caregiving literature (see Zarit entry). Caregivers who provide
support or care to an ill relative often experience deleterious
psychological, physical, and other effects due to the chronic
stress it elicits (Vitaliano et al., 2003). These adverse effects of
caregiving have been shown to be particularly strong for
spousal caregivers (Marks, 1998). This line of research illus-
trates the importance of taking both romantic partners’per-
spectives and experiences into account.
Other than social support, partners in romantic relation-
ships also serve as each others’source of companionship,
which includes enjoyable interactions and camaraderie, such
as shared recreational activities, that partners engage in toge-
ther. In contrast to support, which helps alleviate stress,
companionship is considered a restorative activity that indi-
viduals engage in for enjoyment purposes, and as such, it has
been shown to reduce stress and bolster positive emotions
(Rook, 1987,1995). As noted above, positive emotions are
associated with a number of salubrious effects on health
(Pressman and Cohen, 2005).
Finally, romantic partners often are involved in monitoring
and influencing each other’s health behaviors by engaging in
health-related social control. Social control refers to indi-
viduals’attempts to monitor and influence another’s health
behaviors. In fact, research suggests that spouses are the most
common network members that engage in social control
toward one another (August and Sorkin, 2010;Umberson,
1992). This can occur both indirectly and directly. The indirect
route occurs by individuals’internalization of role obligations,
such as when a partner seeks medical care to protect their
health for the benefit of their partner (Markey et al., 2007). The
direct route entails providing specific verbal instructions or
using other strategies to exert influence on their partners to
engage in healthy behaviors (Lewis and Rook, 1999;Franks
et al., 2006;Umberson, 1992) (It is of course possible that
romantic partners sometimes engage in influence attempts that
undermine, rather than promote, sound health behavior, but
such attempts tend to be less common among spouses, in
particular; Henry et al., 2013.). Although potentially well-
intentioned, exerting social control on a partner’s health be-
havior may come at a cost. Evidence suggests that while social
control may be effective at behavior change, it also may elicit
psychological distress by implying that the individual is un-
able to successfully engage in these healthy behaviors on his or
her own (Hughes and Gove, 1981;Lewis and Rook, 1999).
As illustrated by the research on the potential ‘dual-effects’
of social control, romantic relationships are complex and
multifaceted and being in a relationship is not inevitably
positive. For example, spousal support efforts can go awry, in
that they can be excessive or incongruent with the recipients’
needs (Coyne et al., 1988). These ineffective types of support
can decrease feelings of self-efficacy, autonomy, and overall
well-being. Spouses also can act in ways toward each other that
are critical, insensitive, or demanding, which are likely to
arouse emotional distress. These emotions, in turn, are asso-
ciated with engagement in poor heath behaviors (Rook et al.,
2010), and also may elicit harmful physiological responses
that, if chronic, can cause wear-and-tear on the body over time
(McEwen and Seeman, 2003). In fact, these negative social
interactions have been found to have a more potent effect on
health and well-being than positive social interactions (Okun
and Keith, 1998;Rook, 1998). This suggests that the quality of
people’s relationships may be much more consequential for
their well-being than is the mere presence or absence of a
significant other (Gottman and Notarius, 2002). Indeed, re-
search has found that being in an unhappy stable relationship
may have a deleterious impact on health (Robles and Kiecolt-
Glaser, 2003;Williams, 2003). This may be particularly
true if the relationship is stressful and presents a strain on
psychological and physical well-being (Burmin and Margolin,
1992;Gottman and Notarius, 2002). Consistent with this
notion, single people have somewhat better health outcomes
than those in low-quality relationships (Glenn and Weaver,
1981;Cummins et al., 1996), and unhappy relationships are
associated with a decreased chance of individuals making
positive health behavior changes, decreased well-being, in-
creased prevalence of mental disorders, greater health prob-
lems, and increased mortality rates (Hintikka et al., 1999;
Robles and Kiecolt-Glaser, 2003;Schafer et al., 2000;Tucker,
2002;Walen and Lachman, 2000). Some research even
Marriage, Romantic Relationships, and Health 47
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suggests that individuals who are in an unhappy or un-
satisfying marriage actually suffer progressive decline in their
health over time (Umberson et al., 2006). Researchers, there-
fore, have cautioned that finding a romantic partner or getting
married is not an antidote to ill health or the key to happiness
(Friedman, 2003;Tucker et al., 1996).
The Role of Relationship Status, Gender, Sexual
Orientation, Age, and Physical Health Conditions
Relationship Status
A large body of evidence exists to suggest that married indi-
viduals are generally healthier, have better health outcomes,
and live longer than unmarried individuals (Wood et al.,
2007). This is due, in part, to married individuals’engagement
in more healthy (and less risky) behaviors compared to un-
married individuals. Yet, other evidence suggests that the
married are more likely to be overweight and exercise less than
the unmarried (Umberson et al., 2010). Research that com-
pares individuals who are married to those that are unmarried
typically treats individuals in the ‘unmarried’category as a
homogeneous group however, without considering unique
effects on divorced, separated, widowed, and never married
individuals. There is evidence, for example, that never married
individuals fare just as well as their married counterparts; it
may be the dissolution of marriage through divorce/separation
and widowhood that is responsible for the deleterious effects
of not being married (see DePaulo entry).
Much research on dating has focused on adolescents and
young adults, with considerable focus on intimate partner
violence in dating relationships (Stets and Pirog-Good, 1987;
Wekerle and Wolfe, 1999), as well as how these relationships
encourage or deter risky health behaviors such as substance
use and sexual behavior (Umberson et al., 2010). More re-
search needs to focus on a broader range of health outcomes,
as well as how dating relationships are related to health among
middle-aged and older adults.
Another type of nonmarital romantic relationship, coha-
bitation, has become more common in recent years (Casper
and Cohen, 2000;Kreider, 2010). Cohabitation before mar-
riage is generally viewed as a socially acceptable transitional
stage that often (but not always) leads to marriage, and it is
becoming increasingly more common as an alternative to
marriage. The exact nature of cohabitation’s effects on health is
unclear. When compared to non-cohabitating individuals,
cohabitating individuals have been found to have an increased
risk of obesity, but also a great likelihood of engaging in less
risky behaviors such as substance use (Umberson et al., 2010).
The evidence is also inconclusive when comparing cohabitat-
ing individuals to their married counterparts, with some
studies finding that cohabitating individuals may have worse
health outcomes (Horwitz and White, 1998), and other
studies finding no significant differences in health between
those who cohabitate and those who are married (Wu et al.,
2003;Musick and Bumpass, 2006). These latter findings sug-
gest that the protective effects of marriage may extend to
cohabitating couples. The conflicting results in the literature
on the health effects of cohabitation may be due to a number
of factors, but one important consideration is age. There
is evidence that young adults and older adults view cohabi-
tation differently. Young adults tend to see cohabitation
as another step in the relationship process, usually the step
preceding marriage. Older adults view cohabitation, in
contrast, as a marriage alternative (King and Scott, 2005;
Brown et al., 2012). Research on cohabitation in older adults
is currently limited to a few studies, but the differences in
the function of cohabitation at different ages may explain
some of the inconsistent findings seen in the literature.
Given the changing cultural and normative expectations for
romantic relationships, there is a need for more research to
examine the health effects of these emerging trends to under-
stand whether cohabitation confers the same benefits as
marriage.
Gender
Research examining men’s and women’s relationship and
health experiences is conflicting (Carr and Springer, 2010).
Some research suggests that men and women experience
similar mortality risks when they are in relationships (versus
not being in relationships; Manzoli et al., 2007). However, in
one classic study, significant gender differences in the pro-
tective effect of marriage were reported such that nonmarried
men had a 250% greater mortality rate than married men, and
nonmarried women had only a 50% greater mortality rate
than married women (Ross et al., 1990). Other research sug-
gests that marital dissolution has a more deleterious influence
on men’s health than women’s(Bloom et al., 1978;Tucker
et al., 1996). Thus, some researchers would argue that men
may confer more health benefits from romantic relationships
than women do, but the extent to which men and women are
uniquely affected by their romantic relationships in specific
health domains has yet to be fully explored. For example, it is
possible that women positively impact their male partners
through health-promoting efforts such as encouraging them to
go to the doctor when they are sick, while men may positively
impact their female partners through other health-promoting
efforts such as encouraging them to participate in physical
activity (Markey et al., 2007). Further, in comparing married
men to married women, it seems that married women may
experience better mental health (e.g., less depression), whereas
married men may experience better behavioral health (e.g.,
less frequent alcohol use; Simon, 2002). The research is in-
conclusive as to whether these gender differences extend to
same-sex couples, and other nonmarital relationships,
however.
Sexual Orientation
In the past few years, civil rights issues among gay and lesbian
couples have taken center stage in the political sphere (see
Moradi entry). In the United States, gay and lesbian couples
have struggled (and in most cases are still struggling) to
maintain rights afforded to their heterosexual peers, such as
legally acknowledged marriage and the ability to adopt chil-
dren. At the heart of the debate about these civil rights issues
lies the assumption that gay and lesbian relationships are
‘different’than heterosexual relationships (Biblarz and Savci,
2010). However, contrary to this belief, research examining
48 Marriage, Romantic Relationships, and Health
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same-sex romantic couples generally has found that these ro-
mantic relationships are extremely similar to heterosexual re-
lationships across a wide range of variables (Markey and
Markey, 2011). For example, same-sex romantic couples and
heterosexual couples report similar levels of affective ex-
pression, intimacy, conflict, relationship commitment, and
overall satisfaction (Blumstein and Schwartz, 1983;Kurdek,
1998,2001,2004). It follows then that men and women in
same-sex relationships should experience similar health
benefits from their relationships than do their heterosexual
peers. Preliminary research supports this notion (Lewis et al.,
2006;Markey and Markey, 2012;Wienke and Hill, 2008).
Further, it has been suggested that a reduction in stigma
that accompanies legally sanctioned civil unions and marriage
equality may offer health benefits to men and women in
same-sex relationships (King and Bartlett, 2006). Other re-
search has found, however, that lesbian, gay, bisexual,
or transgender (LGBT) individuals are at a greater health risk
overall, including higher substance use rates (Hughes
and Eliason, 2002), sexually transmitted infections (Marrazzo
et al., 2005;Stolte and Coutinho, 2002), obesity (Boehmer
et al., 2007), and suicide (Remafedi et al., 1998;Meyer, 2003).
These risks are believed to be socially influenced due to
the stigma associated with being a LGBT person, and thus, are
not inevitable. More research needs to be conducted, however,
to fully understand the impact of LGBT relationships on
health.
Age
Relationships have a cumulative effect on health across the
lifespan. Even before the formation of romantic relationships,
however, parents have a significant influence on health that
lasts into adulthood (Haas, 2008). The role that romantic
partners play in each other’s health differs across age groups,
often corresponding to the life events and health issues that
are salient during a specific period.
The research on how romantic relationships impact health
during adolescence is largely focused on how the dating rela-
tionship can help or hinder health, through its influence on
health behaviors (e.g., smoking, alcohol and drug use, and
sexual behavior; Umberson et al.,2010) and intimate partner
violence (Silverman et al.,2001;Stets and Pirog-Good, 1987;
Wekerle and Wolfe, 1999). During young adulthood, dating
remains common, but individuals also start to cohabitate, as
well as experience other significant life events such as first
marriages, child-bearing, and starting a career. Thus, romantic
partners during this time often serve as buffers to the stress
associated with these new experiences (e.g., Shrout et al., 2006)
and may help regulate important health behaviors during these
transitions (Horwitz et al.,1996). Also during this time, mar-
riage helps to curb substance use, as studies have found that
heavy alcohol and marijuana use declines upon entry into first
marriage in young adulthood (Bachman et al.,1997;Curran
et al.,1998;Duncan et al.,2006). However, romantic partners
can be a source of stress in their own right, given the high rates
of breakups and marital dissolution through separation or di-
vorce during young adulthood (Copen et al.,2012).
In middle and late adulthood, spouses continue to be at
the center of the social network (Antonucci and Akiyama,
1987) and thus remain a consistent and important contributor
to their partners’health. At this time, the effects of marriage
on health can most notably be seen, as couples often face
the management of chronic disease and disability, in addition
to other significant stressful life experiences, including retire-
ment and bereavement. The transition into widowhood is a
significant stressor and can have many adverse effects on
health, such as weight loss and increased mortality risk
(Umberson et al., 2009). The adverse health effects associated
with widowhood may depend on social regulation of health
behaviors from non-spousal sources, however (Williams,
2004).
Physical Health Conditions
The association between romantic relationships and health
may take on a different meaning in the context of a chronic
physical health condition. However, because chronic health
conditions tend to be the result of accumulated insults to the
body over the lifespan (McEwen and Seeman, 2003), it is
difficult to make definitive conclusions about whether rela-
tionship functioning contributes to the development of
chronic conditions; instead, research has focused on how re-
lationships contribute to the management and progression of
these conditions (see Revenson entry).Spouses are the social
network members most often involved in their partners’
chronic illness management (Ell, 1996;Revenson, 1994), and
they are likely to share the overarching goal of promoting
adherence to the prescribed treatment regimen, which often
includes initiation and maintenance of a number of health
behaviors (Franks et al., 2006). Given low adherence rates,
spouses’involvement is typically ongoing, and this long-term
commitment may be a chronic stressor (Revenson et al., 2005).
In this sense, health conditions are considered ‘shared’stres-
sors that both members of a romantic couple often manage, or
cope with, together; in other words, they affect not only the
patient, but also his or her spouse. Whether these joint, or
collaborative, coping efforts pose beneficial or harmful mental
and physical health for both members of the couple depends
on a number of developmental and contextual factors, in-
cluding type and stage of condition, culture, gender, and
marital quality (Berg and Upchurch, 2007).
Implications for Individuals, Practice, and Policy
An understanding of how and why romantic relationships are
related to health and well-being has implications not only for
individuals, but also for medical practice, intervention efforts,
and policy decisions. This is particularly important as demo-
graphic shifts leave a growing portion of the population facing
the burden of chronic disease. Given the integral role that
romantic partners play in each other’s health, it is essential to
extend intervention efforts to involve partners in ways research
indicates to be effective.
Research on the implications of health-related social sup-
port and control suggest, for example, that support is related to
better health behaviors and psychological well-being for both
members of the couple, and that gentler, persuasive control
strategies to influence a partner’s health behaviors are more
effective than heavy-handed, critical strategies (August et al.,
Marriage, Romantic Relationships, and Health 49
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2011, 2013;Lewis and Rook, 1999). This illustrates the im-
portance of designing interventions to benefit both members
of the couple and the relationship without sacrificing the
health or well-being of one partner over the other. Indeed,
some evidence suggests that compared to usual medical care,
psychosocial interventions for couples managing chronic dis-
eases other than dementia are related to less depression and
lower mortality rates among patients, and less depression and
burden among their spouses, particularly when the inter-
ventions are relationship-focused (Martire et al., 2004). These
positive mental health effects may, in turn, have implications
for both patients and their spouses’physical health.
In addition to the research on the health benefits of op-
posite-sex relationships, some evidence suggests that same-sex
relationships have similar effects on health (Markey and Mar-
key, 2011). Most work to date, however, has focused on HIV
and other negative health behaviors and outcomes, and less is
known about more positive indicators of health among LGBT
couples. With recent legislative changes allowing same-sex
marriage in some states, an increasing number of individuals in
the LGBT community may be transitioning into marriages. This
provides an opportunity to understand more about whether
same-sex marriage offers protective effects on health in the
same way as it does for opposite-sex marriages, and potentially
will provide further support for both state and federal legis-
latures to expand this benefit to all members of society.
Conclusion
There is a great deal of research to suggest that romantic re-
lationships, particularly marriage, have beneficial, and at
times, detrimental, effects on health. Yet, relationship norms
in the United States and other industrialized nations are
changing. Although many individuals marry, others never
marry, cohabitate, or divorce (Liu and Umberson, 2008). Very
little is understood about the extent to which alternatives to
marriage confer those same benefits or detriments as marriage
itself. An additional challenge in the study of romantic rela-
tionships and health is disentangling the effects of selection
versus protection in an attempt to understand the causal na-
ture of this relationship. These continued efforts to further
understand how and why romantic relationships are related to
health have implications for the design of interventions that
can promote positive relationship functioning to optimize the
physical and mental health of both members of a romantic
couple.
See also: Behavioral Medicine. Caregiving. Chronic Illness and
Mental Health. Couple Therapy. Divorce and Parental Separation.
Intimate Partner Violence. Lesbian, Gay, Bisexual, and Transgender
Issues. Love and Intimacy. Singles and Mental Health. Social
Support and Mental Health
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