Infidelity and Its Associated Factors: A Systematic Review

ORIGINAL RESEARCH & REVIEWS

BEHAVIOR

Infidelity and Its Associated Factors: A Systematic Review Arezoo Haseli, MSc,1 Mohammad Shariati, MD,2 Ali Mohammad Nazari, PhD,3 Afsaneh Keramat, PhD,4 and Mohammad Hassan Emamian, MD, MPH, PhD5

ABSTRACT

Background: Infidelity can be facilitated and/or inhibited as a result of interrelations among multilevel contexts. Despite the existence of numerous studies about infidelity, there is no developmental model that considers multilevel contexts of factors associated with infidelity. Aim: To review published articles addressing factors associated with infidelity and to apply the ecological model to these factors. Methods: A systematic review of the literature was conducted using the PubMed, Scopus, Web of Science, and PsychoInfo. Literature search was restricted to articles published in English up to June 2018. All quantitative and full-text studies that addressed associated factors with infidelity were included. This study was conducted following PRISMA guidelines. Main Outcome Measures: This article reports a review of the literature on the factors associated with infidelity based on the ecological model. Results: We retrieved 5,159 titles, of which 82 were qualified after the qualitative synthesis. The Ecological Couples Systems Diagram (ECSD) is proposed as a developmental model similar to Bronfenbrenner’s Bioecological Systems Model. There was an inconsistency between variables of microsystem and infidelity engagement. However, the results of some studies indicated the impact of demographic factors, personality traits, and sexual information on infidelity, considering partner characteristics. Variables belonging to a mesosystem had a more stable association with infidelity than those from other systems. In addition, the review reveals the complexity of infidelity, associated with following factors: 68.3% (n ¼ 56) of the studies were based on microsystem variables, 48.8% (n ¼ 40) used mesosystem variables, 19.5% (n ¼ 16) used exosystem variables, 26.8% (n ¼ 22) used macrosystem variables, 6.1% (n ¼ 5) used chronosystem variables, and 50% (n ¼ 41) included variables from 2 or more levels. Clinical Implications: The ECSD can be used not only for assessing couple compatibility in premarital counseling, but also for consulting couples who want to have a long-term romantic relationship. As a potential clinical application, therapists can use the ECSD to assess unfaithful clients and their partners, improving the quality of counseling. Strengths & Limitations: This study reveals different environmental layers of various variables related to infidelity. Determining the effect size of variables associated with infidelity was not possible due to the heterogeneity of infidelity assessment tools and test analysis. Conclusion: Apparently, incompatibility of interpersonal characteristics is more likely associated with infidelity than incompatibility of intrapersonal characteristics. It is important to consider couple compatibility before starting an exclusive relationship, such as marriage, for individuals who intend to maintain a long-term exclusive romantic relationship. Haseli A, Shariati M, Nazari AM, et al. Infidelity and Its Associated Factors: A Systematic Review. J Sex Med 2019;16:1155e1169. Copyright
2019, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.

Key Words: Infidelity; Extradyadic; Unfaithful; Affair; Ecological Model Received October 29, 2018. Accepted April 22, 2019.

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Reproductive Studies and Women’s Health Research Center, Shahroud University of Medical Sciences, Shahroud, Iran;

1

Student Research Committee, School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran;

2

Department of Community Medicine, Tehran University of Medical Sciences, Tehran, Iran;

3

Department of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran;

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Center for Health Related Social and Behavioral Sciences Research, Shahroud University of Medical Sciences, Shahroud, Iran

Copyright ª 2019, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jsxm.2019.04.011

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INTRODUCTION Infidelity has been defined as “a violation of a couple’s assumed or stated contract regarding emotional and/or sexual exclusivity.”1 The secret romantic activity with a secondary partner and violation of relationship exclusivity, such as marriage, often lead to deep pain, loss of trust, and uncertainty.2 In addition, infidelity is considered among the threatening factors affecting the stability, performance, and tolerance of couple relationships and is one of the most frequently cited reasons for marital breakdown and health problems.3 The results of a 2007 meta-analysis of 50 studies showed a lifetime prevalence of infidelity in 34% of men and 24% of women.4 Numerous studies have addressed the factors correlated with infidelity. For example, demographic variables, such as gender, age, and education, can be predictive of infidelity engagement.5,6 Other variables, such as insecure attachment, relation dissatisfaction,7 and higher socioeconomic status,8 have been associated with high levels of infidelity. Today, religious affiliation can play an important role in engaging in infidelity.9 Clearly, a comprehensive understanding of infidelity and its interactions with the surrounding environment requires investigation of related factors. People’s behaviors are affected by interpersonal factors, social contexts, organizational structure, and processes because of spending a major part of a person’s life within them.10 Given that infidelity behavior can be facilitated and/or inhibited as a result of interrelations among multilevel contexts, the social-ecological systems theory can provide an appropriate description of this behavior.3 The ecological model is likely one of the few methods that can describe the interactions among various factors and components of phenomena or behaviors like infidelity in real life. In addition, it provides an overview of human behavior instead of a single-dimensional view.11 The present study had 2 main objectives: to clarify and summarize the variables associated with infidelity and to apply the ecological model proposed by Bronfenbrenner to infidelity.

METHODS This systematic review was carried out following PRISMA guidelines.12

Search Strategy The PubMed, Scopus, Web of Science, and PsychoInfo databases were searched from inception to June 2018 for papers published in English using the following search terms: “extramarit* or unfaithful* or infidelity or disloyal* or betrayal or affair or cheating” or “experiencing relationship distress” or “sexual activity outside marriage” or “extradyadic involvement” or “secret romantic realation” AND “relat* or relevant* or associate* or affiliate or predict* or correlate* or dependent* or risk”. The search strategy used for searching in the one of the databases is described in Appendix A. The reference lists of the articles

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included in this review were manually screened for other possibly eligible studies.

Eligibility Criteria In this study, we considered all types of infidelity, including sexual and/or emotional infidelity, in both the real world and virtual worlds. To evaluate the factors associated with infidelity, the eligible studies had to meet the following criteria: (i) having a (part of) quantitative study design, addressing the factor(s) associated with infidelity; (ii) being reported in English; (iii) and being a complete manuscript (not abstract only). Conference abstracts, case reports, reviews, and editorials were excluded. In addition, studies conducted in a specific group of populations, such as infertile women, were considered nonrepresentative samples and excluded from this review. Studies in which the results were a comparison of factors associated with sexual and emotional infidelity, and not infidelity engagement itself, were also excluded.

Study Selection and Data Extraction 2 authors (A.H. and M.S.) screened the titles and abstracts of all retrieved records, and then the full texts independently. Cohen’s k index was calculated. When there was disagreement on whether a study met the inclusion criteria, the article was reviewed by a third author (A.K.) and then selected or discarded by consensus. The following variables were then extracted from the studies included in the systematic review by A.H. and M.S.: author’s name, year of publication, country, study design, sample size, gender, orientation, age, tool to assess infidelity, and primary results (variable predicting/associating infidelity, effect size), as well as ecological level proposed by Bronfenbrenner10: microsystem, mesosystem, exosystem, macrosystem, or chronosystem. To synthesize the results, the factors associated with infidelity were classified based on the ecological model, and then this model was applied to infidelity.

Assessment of Methodologic Quality All 82 included articles were assessed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. The STROBE checklist includes 22 items. Scores range from 0 to 22, with higher scores indicating higher quality.13 The quality of studies is also classified into 3 groups based on STROBE scores: low (<6.5), medium (6.5 to 16), and high (>16). This assessment was conducted independently by 2 researchers (A.H. and M.S.); inconsistencies were settled by the third author (A.K.) and then by consensus.

RESULTS Study Selection A flowchart of the study is presented in Figure 1. A total of 3,026 studies were retrieved from the PubMed, Scopus, Web of Science, and PsychoInfo databases. After 1,003 duplicates were J Sex Med 2019;16:1155e1169

1157 Additional records identified through other sources (n = 0 )

Records identified through database searching (n = 3,026)

Eligibility

Screening

Identification

Infidelity and Its Associated Factors

Records removed for duplication (n= 1,003)

Records screened (n = 2,023)

Full-text articles assessed for eligibility (n = 108)

Included

Studies included in quality appraisal (n=82)

Records excluded after screening titles and abstracts (n = 1,915)

Full-text articles excluded, with reasons (n = 29) -Qualitative research (n=22) -Not representative sample (infertile women) (n=1) -The results present associated factor with sexual compared with emotional infidelity with Reaction Infidelity Questionnaire (n=6)

Studies included in qualitative synthesis (n = 82)

Figure 1. Flowchart of study selection. Figure 1 is available in color online at www.jsm.jsexmed.org.

removed, 2,023 reports were screened for the titles and abstracts. From this screening, 1,915 citations irrelevant to the research topic were excluded. Based on full-text reviews of the 108 remaining studies, 29 articles were excluded, including 22 studies involoving qualitative research, 1 study conducted in infertile women who were not a representative sample, and 6 articles reporting factors associated with sexual infidelity compared with emotional infidelity. The remaining 82 studies were included in this systematic review. Of note, 6 studies had a mixed-method design, but the quantitative part met our inclusion criteria, and only the quantitative sections of these studies were reviewed.

Assessment of Methodological Quality Cohen’s k index was 0.798, indicating substantial agreement between 2 raters.14 The quality assessment is detailed in Appendix B. The quality of the included studies ranged from 9 to 18.1 out of 22 for the 82 studies evaluated with the STROBE checklist. Thirteen studies (15.9%) were deemed of high quality (score >16), and the remainder (84.1%) were of medium quality (score 9 to 16). These results show that in general, the quality of the included studies was moderate to high.

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Characteristics of Included Studies The articles reviewed, published between 1979 and 2018, are characterized in Appendix C. Eighty-nine percent of the studies were of cross-sectional design (including 8.5% online crosssectional and 7.3% mixed-method studies), and 11% (n ¼ 9) were of longitudinal design. The majority of the studies were conducted in the United States (46; 56.1%), with 12 (14.6%) conducted in Asia, 11 (13.4%) conducted in Africa, 6 (7.3%) conducted in Europe, and 2 (2.4%) conducted in multiple continents. The location of 2 studies (2.4%) was unclear. Regarding gender, 65 studies (79.3%) included both men and women, 11 (13.4%) included only men, and 6 (7.3%) included only women. Finally, 22 studies (26.8%) included heterosexual participants, 10 (12.2%) included participants with different types of sexual orientation, and 50 (61%) did not report information about sexual orientation. The authors of the selected articles assessed infidelity using 21 different instruments and items derived from self-reports or self-made questionnaires (Appendix C). The most frequently used questionnaires were the Dyadic Adjustment Scale (Spanier 1976) and the Susceptibility to Infidelity Scale (Buss and Shackelford, 1997).

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According to the ecological model, microsystem variables were assessed in 56 studies (68.3%) of studies, mesosystem variables were assessed in 40 studies (48.8%) of studies, exosystem variables were assessed in 16 studies (19.5%) studies, macrosystem variables were assessed in 22 studies (26.8%), chronosystem variables were assessed in 5 studies (6.1%) studies, and 2 or more levels were assessed in 41 studies (50%).

RESULTS AND DISCUSSION Applying the Ecological Model to Infidelity Applying ecological approaches is particularly suitable for factors associated with infidelity. Some unique behaviors such as infidelity, which have a complex interaction with the environment,10 sometimes are not appropriately ascribed to an individual’s behavior and may be ascribed to a new system.15 Couple relationships are inherently interdependent, and each partner’s behavior can affect the other’s. Therefore, it is difficult to understand the behavior of 1 partner without considering the other.16 A new concept was developed in which a couple’s system acts as a union system in dyadic exclusivity. Based on this concept, a partner’s characteristics and relations may (not) provide a context for his or her partner to engage in infidelity. In other words, infidelity often (not always) is a product of 2-sided couple’s behaviors, although it may be accomplished by 1 or both partners.

Marital informaon Couple relaonship Sexual sasfacon Aachment style

Based on this hypothesis and the overview of primary studies, a union system comprising 2 microsystems (individual and his or her partner) was developed, termed the Ecological Couples System Diagram (ECSD) (Figure 2). Other systems (eg, exosystem, macrosystem, chronosystem) affect the ECSD. Jones et al17 has presented a similar sexological system that provides an ecological model and assessment approach for sex therapy. In comparison, the ECSD is a conceptual model of associated factors with infidelity as a union system that interacts with all different systems in ecological systems theory. Consistent with this idea, Zayas et al16 noted that a partner’s personality is a powerful situational factor in predicting individual behavior. In addition, satisfaction with romantic relationships is influenced by the extent to which a partner complies another one’s most important needs.18 Based on the ECSD, incompatibility in some couples’ characteristics is more likely than incompatibility in some individual’s characteristics to lead to engaging in infidelity, as clearly reported in some primary studies. For example, the role of income level in the prediction of infidelity depends on partner’s income,19 and also on personality traits,20 attachment style,21 sexual values,3 and other characteristics. Thus, these variables have a dyadic effect on infidelity engagement.16,19e21 In fact, it seems that incompatibility within a couple can predict infidelity engagement. This result is confirmed by the

process

process

process

Time: Chronosystem

process

process

Couple’s Mesosystem

Microsystem

Microsystem

Partner 1

Opportunity: Social media Occupaon Urban residence Home instability Social life Travel

Partner 2

Individual and partner Characteriscs: Socio-demographic Psychological and biological factors Personality traits Sexual informaon Atudes toward infidelity Infidelity experience Sexual funcon and dysfuncon Alcohol consumpon Parent’s characteriscs: Infidelity, divorce and marital sasfacon

Religion Spiritual acvies Race Ethnicity Gender role, equity and norm Cultural masculinity

Figure 2. The Ecological Couple's Systems Diagram. J Sex Med 2019;16:1155e1169

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cognitive dissonance theory,22,23 which has reported incompatibility within the couple as one of the most common causes of infidelity. Couple incompatibility can be in education, economic status, religiosity, customs, sexual values, sexual attraction, and communication. Incompatible couples engage in infidelity more than others, which leads to disconnection in couple relationship, as if they have never been actually married.24 The understanding and response of the 2 partners in interacting with other systems, such as exosystems, macrosystems, and chronosystems, differ when there is incompatibility within the couple. Therefore, incompatibility will be created not only within the couple, but also between the couple and other systems. Consequently, these individuals may ignore the couple’s stated or assumed contract regarding emotional and/or sexual exclusivity and become more engaged in infidelity.23 The microsystem of the ECSD not only includes information about individual and partner characteristics (bioecological system), but also might involve sexuality issues, including sexual desire, sexual interest, and sexual excitation. Infidelity engagement may be linked to interactions with a sexual partner, such as the partner’s hypoactive sexual desire or anorgasmia.25 It also may be developed from very early interactions with parents, for example, an unfaithful or divorced parent.26,27 Experiences within each microsystem will lead to all the personal scripts surrounding individual and couple sexual behaviors, such as sexual infidelity. The mesosystem comprises the reciprocal interactions that take place among the microsystems within an individual’s life.10 Although a couple is defined as a union system, communicational interaction between 2 partners is affected not only by everyone’s partner, but also by other system interactions. This subsystem emphasizes surrounding interpersonal relationships.17 The most frequent variables in a couple’s mesosystem are marital and sexual dissatisfaction; however, there have been few studies addressing quality, interaction, happiness,28 instability, and conflict in a marital relationship with the same results. The exosystem includes a situation or institutions that affect an individual’s daily settings but are not part of the individual’s immediate environment.10 The exosystem of the ECSD can include public debate and acceptance/rejection over infidelity, as well as opportunities for it. Certain variables, such as social media, occupation, urban residence, home instability, social life, and travel, are classified as societal variables because they are theoretically related to infidelity by creating an opportunity and a facilitative context for sexual or emotional infidelity.29 Opportunity refers to the availability and willingness of the third person, as well as factors that facilitate secret contacts from the spouse.30 The macrosystem of the ECSD comprises cultural and societal principles with broader influences on couple’s system that lead to infidelity. Traditional value systems condemn infidelity, but these norms are changing.31 Cultural beliefs and values of a country can also have a significantly direct or indirect effect on J Sex Med 2019;16:1155e1169

human behavior (eg, infidelity) and determine what is considered right or wrong behavior within a society.10 Today, the type, functions, and characteristics of marriage vary among cultures, and these can change over time. Consequently, social constructions about infidelity are changing, making it important to understand the social context of a new sexual behavior and its related factors.32 The chronosystem of the ECSD consists of changes relating to time or throughout the lifecycle that influence individuals and their environment.33 For example, when a couple’s lives are shared and merged, their chronosystems are also shared and merged. The chronosystem continuously changes and evolves over time. Thus, the chronosystem of the ECSD refers to life events that either indirectly affect an individual’s desire and psychological processes to engage in infidelity (eg, partner with an illness, partner’s suspected affair) or directly influence his or her experience of infidelity, such as divorce history, previous infidelity, or sexual abuse.9,34e37 We next describe the factors associated with engaging in infidelity, as conceptualized through Bronfenbrenner’s ecological systems theory. However, it is important to recognize that these factors are descriptive and do not completely characterize all the factors that might possibly influence infidelity engagement.

Microsystems Numerous microsystems form throughout an individual’s life. However, based on the present systematic review, certain microsystems have been identified as significantly influencing infidelity engagement, including individual, partner, and parent characteristics. Individual Characteristics Individual characteristics include sociodemographic factors, psychological and biological factors, personality traits, sexual information, attitudes toward infidelity, infidelity experience, and alcohol consumption.

Sociodemographic Factors. The closest level to the individual is the microsystem that includes sociodemographic factors that can influence processes in the individual’s immediate environment. Sociodemographic variables are mediators and may interact with the partner’s sociodemographic factors, such that whenever individual and relational factors overcome a person, the role of sociodemographic factors is diminished. Gender has been repeatedly related to infidelity with men identified as more likely to engage in this behavior than women.34,36e41 Based on the ECSD, cultural issues and social norms responsible for sexual behaviors such as infidelity lead to the acceptability of it in men and blame for it in women.42 In the other hand, people are less likely to admit the behaviors that transgress social conventions.43 In this regard, women may be more likely than men to underreport infidelity, considering the

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social backlash that women receive compared with men for the same behavior.44 Age8,34,45 and education19,36,37,46,47 were 2 of the weakest predictive factors for infidelity, because the results of studies on age have been contradictory. The experiences, skills, sexual functions, and motivations of people vary at different ages, even if their immediate environment is the same.16 Bronfenbrenner postulates that human behavior is influenced by individuals and contexts, such that not everyone will experience them in identical fashion.10 Experience with premarital sex,48 childhood sexual abuse,49 and motivation for infidelity50 are able to mediate the effect of age on infidelity. Above all, it is necessary to pay attention to the age of the partner. Power and income are considered resource characteristics that increase infidelity engagement. According to the ecological model, 2 people may have equal resource characteristics, such as high income or power, but their behavior (eg, infidelity engagement) may be quite different; for example, if one is motivated to act and continue it and the other is not.51e53 Psychological and Biological Factors Several mechanisms may plausibly account for the association between psychological distress, such as poor decision making under stress,54 escape confrontation55 increasing negative emotional experiences, and seeking social support,56 and infidelity.57,58 Based on the ECSD, people who are anxious or depressed are more likely to engage in infidelity if their spouse has no supportive role. Biological factors, such as high levels of follicle-stimulating hormone,59 endogenous testosterone,25 and heretical factors,60,61 are known as risk factors for risk-taking behaviors, such as infidelity.62 The association between a committed relationship and reduced testosterone levels in men confirms and extends previous research linking testosterone level with mating effort.63 The effect of biology on sexuality can be described as a predisposing factor that influences sexual interest, desire, and response of individuals64 that predict a greater likelihood of infidelity.65 Personality Certain personality traits, such as neuroticism, have been identified as strong and consistent predictors of infidelity in many studies.20,66e73 In addition, other personality characteristics, including self-regulation, self-expansion, responsibility, selfesteem, and thoughtful decision making, have important roles in infidelity behavior.74e80 Infidelity behavior depends not only on the individual’s personality, but also on his or her partner’s personality.16,81 Personality differences and interactions within the couple are important determining factors of infidelity. Thus, high compatibility scores and similarity between partners in terms of personality are associated with higher levels of marital satisfaction82 and lower rates of infidelity.67

Sexual Information. Sexual information includes previous sexual experience, propensity of sexual excitation, sexual

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attitudes, sexual interest, and age at first intercourse. The rate of infidelity is higher in people who have experienced sexual abuse48,49,83,84 or premarital sex.85 Dysfunctional patterns resulting from neglect or abuse in childhood, include those surrounding intimacy, emotional closeness, and building trust in romantic relationships, can lead to infidelity49; however, a supportive partner relationship can mitigate the effects of bad experiences in childhood.86 Overall, a higher propensity for sexual excitation was associated with increased infidelity.3 Bancfort postulated that individuals with a high propensity for sexual excitation are more likely to engage in high-risk or otherwise problematic sexual behaviors.87 In addition, individuals highly interested in sex might eschew sexual exclusivity and be more likely to have multiple partners because they expect greater pleasure from relations outside of marriage.88 Such sexual attitudes as unrestricted sociosexual orientation and premarital sexual permissiveness are related to greater infidelity.66,89e92 These factors are a part of sexual value system that links a set of religious ideologies, liberal politics, and gender egalitarianism to premarital sexual permissiveness. A couple’s compatibility in a sexual values system is important for those who believe in an exclusive romantic relationship.

Attitudes Toward Infidelity and Infidelity Experience. Studies of the role of attitudes toward infidelity and previous infidelity have shown a positive correlation between such variables and infidelity.35,48,79,93,94 Attitudes have the greatest impact on infidelity behavior, being the key channel through which the intention engage in infidelity is developed. These results are not surprising, given that unfaithful individuals with more liberal sexual attitudes have a higher propensity of sexual excitation,3 which is associated with increased infidelity.

Alcohol Consumption. Intoxication makes people more likely to be involved in extramarital sex.45,85,95,96 Alcohol can affect marital life, given the strong associations between alcohol consumption and violence, negative interactions, and marital dissatisfaction, as well as some empirical evidence of positive effects.97 A discrepancy between couples regarding alcohol consumption is also associated with infidelity. Partner Characteristics An individual’s infidelity behavior is considerably influenced by his or her partner’s characteristics. Our findings suggest that such characteristics as partner’s personality (as mentioned previously), educational background, income, attractiveness, and sexual dysfunction are associated with engagement in infidelity.

Sociodemographic Characteristics (Income and Education). Income has a very complicated role in infidelity engagement. More than money and income, it is a discrepancy in wealth levels that triggers infidelity behavior.19 However, a greater wealth index is associated with greater infidelity only in men.8,45,98 J Sex Med 2019;16:1155e1169

Infidelity and Its Associated Factors

The correlation between one’s own and partner’s income and education in infidelity is nuanced; it likely reflects complex reciprocal interactions of social forces (eg, power, freedom, opportunity) that are not easily captured by simple sociodemographic characteristics and that may be rapidly changing along with larger social changes.

Attractiveness of Romantic Partner. Partner physical attractiveness as predictor of couples’ satisfaction leads to a lower likelihood of infidelity engagement.3 Additionally, the attractiveness of third person was one reason that leads to more likely to engage in infidelity.99 Based on the ecological model, skin color and physical appearance are a part of “personal stimulus” characteristics that act as an urgent stimulus to another person. This is why individuals engage in infidelity when they find other attractive men/women if their partner is not attractive.99 Such a character may influence initial interactions and sexual excitations.100

Sexual Function and Dysfunction. Individuals with sexual dysfunction (eg, premature ejaculation, severely delayed ejaculation) are less prone to engage in infidelity,25 but those who partner has a problem with sexual function (eg, hypoactive sexual desire, anorgasmia) are at increased likelihood of engaging in infidelity.25,101 Here the primary partner has an unmet sexual need that can increase the risk of infidelity. On the other hand, good sexual functioning is associated with lower rates of infidelity.25,65,102 Parental Characteristics Parents represent a highly influential microsystem in terms of sexual socialization.17 Previous infidelity, marital dissatisfaction, and divorce experience in parents are associated with infidelity behavior in their children.27 Parents’ attitudes toward sexual behaviors are transmitted to their children, informing their beliefs about sex and making them accustomed to infidelity behavior.103 Specific behaviors at the parental level, such as parents’ infidelity, are firmly connected with offspring’s equivalent behavior. Interestingly, parents’ satisfaction, conflict, and perceptions of infidelity are also associated with offspring’s infidelity behavior.

Mesosystem The mesosystem of the ECSD includes the couple’s relational variables, such as satisfaction, happiness, stability, conflict, and attachment styles. Marital Information Younger age at marriage104 and first intercourse5,8,45,85 predicted engagement in infidelity. The significantly higher rate of infidelity associated with teenage marriage may be rooted in the situations of these marriages, such as teen pregnancy, parental disapproval, and other issues. These interpretations are purely speculative, however.

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Cohabiting (vs married) status105 and pregnancy72,106,107 have been associated with higher rates of infidelity. This finding suggests that it is cohabiting couples’ lower investment in their unions, not their less conventional values, accounts for their higher risk of infidelity.108 Unmet sexual needs during pregnancy and personal beliefs about the effect of coitus on pregnancy can lead to declining coital frequency and decreased sexual satisfaction, which are significant predictors of infidelity during pregnancy.109,110 Couple Relationship It has been well documented that marital satisfaction and happiness and good dyadic adjustment are associated with a lower rate of infidelity and, conversely, marital dissatisfaction and instability are associated with a higher rate of infidelity.36,40,67,111e114 Huston and Houts115 presented 2 models, the perpetual problems model and the disillusionment model, and provided some evidence in support of these models in demonstrating the deterioration of marital quality over the early years of marriage. Presumably, people who engage in infidelity better exemplify a perpetual problems model, in which marital dissatisfaction is an important element. In this regard, Thompson116 proposed a deficit model to clarify infidelity, in which insufficiencies in the primary relationship play central roles in hastening and sustaining infidelity. He estimated that the quality of primary relationship (eg, low satisfaction, low sexual frequency) reliably accounts for 25% of variance in infidelity.116 Sexual Satisfaction There is a strong correlation between high sexual satisfaction and low infidelity and vice versa.69,70,102,113,117 Individual wellbeing (eg, pleasure, arousal, sexual excitement) and dyadic processes (eg, intimacy, expression of feelings) are 2 major dimensions of sexual satisfaction, such that people who experience a significant decline in sexual excitement may seek to reinforce their sexual satisfaction by engaging in the novel experience of sexual relationships outside of marriage. Moreover, a strong decline in intimacy may be a stressful experience that leads to seeking out of sexual relationships outside of marriage to fill an emotional void related to their primary sexual relationship.118 Attachment Style Insecure attachment styles have been associated with infidelity.7,21,69,119e122 According to Simpson et al,123 “attachment styles have clear and meaningful effects on actual behavior.” The theory of adult attachment provides good examples of multidimensional perspectives on love. Insecurely attached people, who show high avoidance (fearful and dismissing attachment styles), have different patterns of romantic preferences and behaviors than securely attached people.124 They tend to show much less interest in romantic relationships, particularly ones in which a long-term commitment is necessary.125 Consequently, partner attachment style is an important determinant of infidelity (dis)engagement.21

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Exosystem Compared with studies examining microsystem or mesosystem variables, fewer studies evaluated exosystem variables. Social Media People with social networking behaviors are more likely to engage in infidelity.71,88,126e128 High levels of social media use can damage an individual’s interpersonal relationships and thus provides a potential source of relationship conflict and dissatisfaction.126 Social Life Social life (ie, spouse/partner-absent activities outside the regular work hours, including entertaining, dinner parties, calling on friends, and group travel) is associated with infidelity in men.89 A man who spends most of his leisure time with friends or others than his partner will encounter more opportunities for infidelity. Concurrently, a partner who is left alone and feeling forgotten is also more likely to engage in infidelity. Although loneliness has been suggested as a factor associated with infidelity,114 this association remains speculative. Occupation People are more likely to engage in infidelity with an oppositesex coworker.34 A workplace sex-mix has a greater correlation with divorce in women compared with men.129 This finding may be rooted in reproductive biology; compared with women, men are more likely to engage in infidelity rather than divorce a wife considered an unacceptable mate.130

Macrosystems In the ECSD, religious and spiritual practices, race and ethnicity, and cultural factors are considered to constitute the macrosystem. Religion and Spirituality One of the most important factors in how the macrosystem affects infidelity is through religion. Extramarital sexual activity is a prevalent concern for religious groups and traditions, all of which condemn it, although they differ in the strength of these norms.131 However, in practice, the association between religion and infidelity is inconsistent. Some studies have found that people with low levels of religiosity are less likely to engage in infidelity9,19,36,38,72,96,105; however, other studies have demonstrated no differences in rates of infidelity as a function of religious practice.3,45,78 The powerful impact of religion may be related to several factors. Today, religious groups are being affected by globalization, which is diminishing their ability to maintain exclusive social networks that can restrict sexual behavior among their adherents.9 Spiritual activities, such as prayer, sanctification of marriage,132,133 and the inspired word of God,9 are associated with less infidelity. When God is considered the third partner in

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marriage, the couple’s commitment to the relationship increases. God, through prayer for the spouse and the sanctification of marriage, becomes an integral part of the marital relationship. In fact, spirituality provides stability through emphasizing a sustained and stable marriage.134 Culture Cultural attitudes and beliefs about marriage, such as a bride price paid by the groom to the bride’s family, are associated with a lower rate of infidelity in women but a higher rate of infidelity in men, possibly related to the men’s sense of entitlement to engage in infidelity.135 Cultural beliefs and values of a country can have a considerable effect on human behaviors, including infidelity.10 Race and Ethnicity Although numerous studies have reported higher infidelity behavior among blacks9,19,47,48,105 and African Americans,9,47,88 other studies do not support this conclusion.34,37 Higher rates of incarceration and other social contextual factors in these communities can lead to the unavailability of desired primary partners.72 Gender Roles, Equity, and Norms and Cultural Masculinity The most salient components of how the macrosystem affect infidelity are gender roles,102 equity,104 and norms.90 In some societies, the norm is more accepting of infidelity in men than in women, and in fact in some societies women are even punished for it. Men also generally experience lower levels of anxiety, fear, and guilt related to infidelity compared with women.136 Consequently, men more often engage in infidelity and less often are blamed for it.

Chronosystem As mentioned earlier, in the ECSD, the chronosystem might have differing effects on a marriage over time and interact with various other issues facing the couple. For example, people who have recently experienced divorce are in a critical situation. The experience of separation or divorce confers a risk for poor health outcomes and considerable emotional distress. Thus, it is both directly137 and indirectly (eg, psychological factors)138 associated with infidelity. During such a critical period, people need understanding, sensitivity, and emotional support so that their lives can continue normally until the crisis ends.139

Interactions Across Systems Infidelity is affected by complex multilevel ecological factors, and the influence of factors within and between systems must be considered in any ecological theory. Bronfenbrenner advanced the concept that human existence is so complex such that to understand factors associated with infidelity, we must first know and then account for all factors at play. The concept of interacting systems influencing infidelity is a component in the work J Sex Med 2019;16:1155e1169

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of many investigators attempting to develop models that predict infidelity. Unlike many studies that focused solely on factors within interpersonal characteristics,140e142 Jackman presented a theory of planned behavior to identify factors correlated with infidelity intention.143 Although this theory provides for multisystem aspects contributing to infidelity, an important limitation in its application to infidelity is the exclusion of environmental and economic factors that may influence a person’s intention to engage in infidelity. In the ECSD, although numerous factors were examined from the microsystem level to the macrosystem and chronosystem levels, the effect size of each variable was not analyzed, owing to the high number of variables and the heterogeneity of analyses, infidelity assessment tools, and related factors. Next, we discuss 3 approaches to presenting the results of this review and interactions across systems. The first approach is to report which factors have the closest association with infidelity. Our overview of primary studies identified sexual narcissism (odds ratio [OR] ¼ 9.02; P < .05),70 sexual and physical abuse (OR ¼ 6.22; 95% confidence interval ¼ 3.98e9.72),84 previous infidelity, cohabitation, cybersex, premarital sex, older age, alcohol consumption, economic dependency, marital dissatisfaction and unhappiness, gender role, and higher educational level (OR >2; P < .05) as the major factors in this regard. This approach is not valid because this information is an output of the primary studies and not meta-analysis results. The second—and possibly better—approach is to report which system has the closest association with infidelity. Although 68.3% of studies reported at least 1 variable of a microsystem associated with infidelity, the results are inconsistent, especially in terms of demographic characteristics. Nonetheless, the results of some studies indicate the impact of certain demographic factors, personality traits, and sexual information on infidelity considering the partner’s characteristics. All the evaluated studies that assessed the association between a couple’s mesosystem and infidelity concluded that a positive interpersonal relationship is correlated with a lower incidence of infidelity engagement. Consequently, the factors with a more stable association with infidelity were identified as variables belonging to the mesosystem. The third—and possibly best—approach is based on the ECSD-identified factors associated with infidelity. As noted by Bronfenbrenner,51 a genuine effect within and between systems leads to infidelity or its hindrance. In other words, infidelity occurs when a system is basically in trouble and has a high effect such as incompatibility in personality,20 or when more than 1 system is in trouble leads to reinforcing the effect size of each system. Nevertheless, some of these factors play key roles in each of the systems, for example, gender role or religiosity as a macrosystem.79 Moreover, incompatibility of interpersonal relationships (ie, the couple’s mesosystem) has an important role in infidelity engagement, with positive relationships associated with lower J Sex Med 2019;16:1155e1169

infidelity engagement and, conversely, negative relationships associated with higher infidelity engagement. The most dominant variables in a couple’s mesosystem are marital and sexual satisfaction. An individual’s decrease in relationship satisfaction may lead to a perception of greater intimate value than is shared by his or her romantic partner. The availability of highly desirable alternatives can lead to “mate-switching.”144 Although many societies view infidelity as “deviant” behavior, and cultural scripts commonly emphasize exclusive romantic relationships,131 today, for some people, sexual infidelity demands considering all pros and cons. Treas and Guesen88 hypothesized a “reward-cost balance” for engaging in infidelity and mate-switching. Other have hypothesized that relationship satisfaction as an internal regulatory variable acts to calibrate relationship behaviors and can be responsible for fitness costs and benefits of the marital relationship.145 Thus, a greater level of satisfaction with the relationship may vaccinate a couple’s system against infidelity and mate switching if both partners desire and believe in a long-term exclusive romantic relationship.

Rationale for Using the ECSD in Infidelity The premarital period is meant to be one of preparation toward fidelity and compatibility for people who desire a long-term romantic relationship.146 Optimally, when a couple presents for premarital counseling, both partners are asked to answer a written questionnaire to determine how each feels about the other and the relationship. This can help guide the therapist in identifying strengths, weaknesses, and potential problem areas, such as a difference in sexual values in the couple. The therapist may conceptualize and handle the presented problem as a microsystem; however, other systems, such as the macrosystem, have major effects on sexual values,17 such that they cannot be separated from current and previous sexual influences and interactions. In addition, the couple’s compatibility in personality, attachment, and other factors cannot be separated, at least for those desiring a long-term exclusive romantic relationship. We suggest an approach to premarital counseling in individuals who want to initiate an exclusive romantic relationship based on the ECSD. In this model, the couple relationship is conceptualized as its own systemic structure with complex reciprocal interactions, along with all of different systems referenced in ecological systems theory (Figure 2). It is important that the couple understand that there are numerous related factors that may lead to infidelity engagement during life of the relationship. The first step involves assessment of each individual’s sociodemographic factors, sexual values, personality traits, attachment styles, religiosity, and other aspects, followed by the compatibility of these factors within the couple. In the second step, assuming the compatibility of the couple, factors in maintaining a long-term exclusive romantic relationship are explored. As shown by the results of the present review, positive relational factors are correlated with a lower rate of infidelity, and

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promoting relationships through education may lead to less infidelity engagement.147 Considering the interaction of interpersonal factors with other systems, the ECSD can also be used as an educational and consulting tool to highlight the multiple systemic influences on each person’s romantic relationships. In this context, an educational program, the Prevention and Relationship Enhancement Program (PREP), was developed to help strengthen couples’ relationships and enhance their commitment to marital life.148 The results of the present review can be integrated into the PREP framework to establish the groundwork for a successful and healthy marriage without infidelity in couples who seek a long-term exclusive romantic relationship.

Study Strengths and Limitations To the best of our knowledge, the present study is the first review of factors associated with infidelity to present a unique ecological model of engagement in infidelity. In this review, we also considered partners’ characteristics as well as individual characteristics as part of the ECSD. The ECSD, as outlined in this review, was developed as a potential assessment and educational tool for premarital counselors to assess and educate their clients desiring a long-term exclusive romantic relationship about the various factors contributing to infidelity. This review reveals different layers of environmental variables related to infidelity. More importantly, the model can be used to expand comprehensive intervention approaches that systematically address mechanisms of change at each level of influence. The inclusion of a large number of studies exploring the factors associated with infidelity can be considered a strengths of this review, which led to our application of the ecological model to infidelity. However, we did not find any studies evaluating such variables as laws and policy that may be associated with infidelity. There are some limitations of the review at both the study level and the review level. The primary studies were mainly limited to samples from the United States; whether our findings can be generalized to other cultures is unclear. In the primary studies evaluated, infidelity was assessed using a variety of instruments. One-third of the included studies used reliable scales, but the remainder used 1-, 2-, or 3-item selfcreated questionnaires. The measurement of critical social behaviors (such as infidelity) is more accurate when done with validated tools compared with other tools.149 In terms of study methodology, the majority of articles (81.7%) were crosssectional studies, and only 11% were longitudinal. For the exploration of infidelity, a longitudinal study provides a better understanding of development of infidelity and its predictive factors.30 As shown in Appendix C, some studies used correlational analysis and thus did not identify which circumstances yield the former and which yield the latter.

Haseli et al

As mentioned earlier, we could not analyze the effect size of each variable on infidelity owing to the heterogeneity of analyses, tools for infidelity assessment and related factors, study setting, and orientation. Another limitation of this review is that we included only scientific papers published in the English language in which infidelity was the dependent variable.

Clinical Implications Assessment of a couple’s compatibility is an important component in premarital counseling for persons desiring a longterm exclusive romantic relationship. This assessment can include sociodemographic factors, personality, attachment styles, sexual values, and other aspects. The findings of the present review can be integrated with PREP and healthy marriage programs in couples counseling. Using this model, therapists can better identify the factors affecting infidelity and provide the appropriate counseling for couples not only in premarital counseling, but also during married life. Also, as a potential clinical implication, the ECSD could be useful for assessing and counseling unfaithful clients and their partners.

CONCLUSION In the present study, Bronfenbrenner’s ecological systems theory was adopted as a conceptual framework. Our analysis demonstrates that infidelity is affected by complex reciprocal interactions of multilevel ecological factors that help couples expand their awareness of risk factors for infidelity that can lead to an increased sense of responsibility for the care of their spouse in both partners. Our findings indicate that incompatibility of interpersonal characteristics, such as sociodemographic factors, personality, attachment styles, and sexual values, is more closely associated with infidelity engagement than are the intrapersonal characteristics themselves. It is important that a couple’s compatibility be considered before initiating an exclusive relationship, such as marriage. In all the evaluated studies, a couple’s mesosystem or interpersonal relationship had an important role in infidelity, with a positive relationships associated with lower infidelity engagement and vice versa. Considering fidelity and commitment as 2 main components of a healthy marriage,148 this result indicates the need to strengthen the mesosystem for healthy marriage providers to accomplish this goal, perhaps through the application of the ECSD. Moreover, the ESCD may be helpful in planning interventions. The ECSD can be used as a consulting tool for premarital counseling, marriage enrichment, couples therapy, marriage mentoring, and marriage education in couples who desire a long-term exclusive romantic relationship with their partner. Corresponding Author: Mohammad Shariati, Tehran University of Medical Sciences, Tehran, Iran. Tel: þ989121951065; E-mail: [email protected] J Sex Med 2019;16:1155e1169

Infidelity and Its Associated Factors

Conflicts of interest: The authors report no conflicts of interest. Funding: This study was supported by Shahroud University of Medical Sciences as a part of a PhD thesis (ethical code IR.SHMU.REC.1397.017) and a grant (9736).

STATEMENT OF AUTHORSHIP Category 1 (a) Conception and Design Arezoo Haseli; Mohammad Shariati; Ali Mohammad Nazari; Afsaneh Keramat; Mohammad Hassan Emamian (b) Acquisition of Data Arezoo Haseli; Mohammad Shariati (c) Analysis and Interpretation of Data Arezoo Haseli; Mohammad Shariati; Ali Mohammad Nazari; Afsaneh Keramat; Mohammad Hassan Emamian Category 2 (a) Drafting the Article Arezoo Haseli; Mohammad Shariati (b) Revising It for Intellectual Content Arezoo Haseli; Mohammad Shariati; Ali Mohammad Nazari; Afsaneh Keramat; Mohammad Hassan Emamian Category 3

1165 9. Burdette AM, Ellison CG, Sherkat DE, et al. Are there religious variations in marital infidelity? J Fam Issues 2007;28:15531581. 10. Bronfenbrenner U. Ecological models of human development. Int Encycl Educ 1994;3:1643-1647. 11. Griffore RJ, Phenice LA. Proximal processes and causality in human development. Eur J Educ Dev Psychol 2016;4:10-16. 12. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 2009;6:e1000100. 13. Von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. PLoS Med 2007;4:e296. 14. Tang W, Hu J, Zhang H, et al. Kappa coefficient: A popular measure of rater agreement. Shanghai Arch Psychiatry 2015;27:62. 15. Rothbaum F, Rosen K, Ujiie T, Uchida N. Family systems theory, attachment theory, and culture. Family Process 2002 Sep;41(3):328-350. 16. Zayas V, Shoda Y, Ayduk ON. Personality in context: An interpersonal systems perspective. J Pers 2002;70:851900.

(a) Final Approval of the Completed Article Arezoo Haseli; Mohammad Shariati; Ali Mohammad Nazari; Afsaneh Keramat; Mohammad Hassan Emamian

17. Jones KE, Meneses da Silva AM, Soloski KL. Sexological systems theory: An ecological model and assessment approach for sex therapy. Sex Relation Ther 2011;26:127144.

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SUPPLEMENTARY DATA

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Supplementary data related to this article can be found at https://doi.org/10.1016/j.jsxm.2019.04.007.

J Sex Med 2019;16:1155e1169