- What are the psychosocial needs and vulnerabilities of older gay and bisexual men?
Key take-home messages
- Health outcomes related to the intersectionality of aging and sexual minority status is an emerging area of research (1, 2).
- It is important to consider the context of lived experiences among older gay men (3, 4), as their experience of aging may be different from their heterosexual counterparts (3).
- The construct of internalized gay ageism appears to be a form of sexual minority stress that may have negative impacts on the psychological well-being of older gay men (5).
- Generally, being part of the gay community or being active in gay-affirmative spaces was identified as being beneficial and may potentially influence health outcomes (3, 4, 6).
- Support groups specifically targeting older gay men living with HIV may decrease perceived stigma and have a positive impact on quality of life (7).
The issue and why it’s important
Within the general population of ageing adults, sexual minorities are an often-hidden group (8). In 2018 in Canada, 4% of individuals older than the age of 15 identified as members of the LGBTQ2+ community (lesbian, gay, bisexual, transgender, queer, Two-Spirit, or those who identify with another non-binary gender or minority sexual identity) (9); of these, 7% were aged 65 or older (9). Despite being a small proportion of the population, in recent years research on aging sexual minorities has increased: authors of a 2019 systematic review describe this field of research as having grown rapidly since 2010 (1).
A 2016 study on LGBT adults in the U.S. notes that “[p]eople are shaped, in part, by the defining cultural mores and social climate of their formative years” (10). This is of particular significance for older sexual minorities today, as these individuals likely experienced mistreatment and discrimination before the progression of social attitudes and equal treatment (10). Fredricksen-Goldsen (2014) describes the life experiences of sexual minorities from mid-life to older as vast: individuals born before 1946 grew up in a time when non-normative sexual identities were stigmatized and criminalized, while those born between 1946 and 1964 came of age during unprecedented events that fostered social change (e.g. the Stonewall riots, the height of the AIDS pandemic) (11). These life experiences are considerably different compared to that of the general population, and for some older sexual minorities, has resulted in health disparities (12).
Accordingly, a 2016 systematic review across 41 studies from high-income settings found that those aged 60 years and older who identify as lesbian, gay, or bisexual encounter psychosocial factors that uniquely influence the experience and process of ageing (13). Among aging Canadians, a 2018 study found that sexual minorities over the age of 45 were more likely to report poor mental health outcomes such as anxiety and depression compared to heterosexuals (14). This particular topic — the intersectionality of aging and sexual minority status — has been described as an emerging area of clinical research (2). Other literature has supported this notion, suggesting that sexual minorities have unique health care needs beyond the HIV epidemic that extend to overall health and wellbeing (15, 16).
This review focuses exclusively on the psychosocial needs and vulnerabilities of older gay and bisexual men and explores several issues salient to these needs, including: the socio-historical context, social networks, minority stress theory, aging with HIV, and resilience.
What we found
The social-historical context and social networks
Research has demonstrated that significant social-historical events — especially the AIDS epidemic (17) — have influenced the social lives of older gay men (4). An in-depth qualitative study among ten White, urban, well-educated gay men aged 65–77 used interviews to elicit understanding of participants’ social lives (4). The significance of “lived-through” events was noted, such as the criminalization of same-sex behaviour, pathologization of homosexuality, moral condemnation from religious institutions, acts of resistance, and the sexual liberation movement, which all shaped the social lives of the participants (4). Some of these events, such as homophobic legislation, dominated the adult lives of the participants and negatively impacted their relationships with others (4). Conversely, events like those that followed the Stonewall riots had a positive impact on their lives (4). It also should be noted that these life experiences are considerably different from that of younger gay men (5). Wight et al. note that “[m]idlife and older gay men have traversed unparalleled historical changes across their adult lives and have paved the way for younger generations of sexual minorities to live in a time of less institutionalized discrimination” (5). Nonetheless, negative attitudes towards sexual minorities continue to persist (4).
One significant lived-through event for the older generation represented in the study was the HIV/AIDS epidemic (4). Participants represented a survivor cohort, with one individual noting that “HIV negative and HIV positive older gay men have all gone through what has been a holocaust. They’ve all been affected by it and they’ve all lost scores of friends and lovers” (4). Indeed, the loss of several intimate connections and the trauma caused by the AIDS pandemic was an overarching theme that negatively impacted the participants and their social networks, and had a lasting impact on their lives (4). Several participants were still coping with the grief resulting from it (4).
Participants highlighted the importance of services within the gay community in order to cope with the challenges faced over the life course (4). Historically, these services were relied upon to contend with the HIV/AIDS crisis and the stigma associated with being gay; currently, the community was being used to cope with current difficulties faced by older gay men, including meal preparation, illness, loneliness, retirement planning, and dating (4). Overall, being part of the gay community and being in gay-affirmative spaces provided benefits that were highly valued (4).
Other research has explored the organization of social networks specifically, noting that these networks are organized differently for some gay men because they have been ostracized by their families and geographic communities of origin (18, 19). A qualitative study among 20 older gay men in Atlanta (aged 60-83, median age 68) examined key factors that shaped the meaning of a quality social network (18). From the interviews, authenticity — that is, having a collection of individuals in their lives with whom they could fully be themselves — was identified as being a central concept (18). Men with high-quality networks had numerous ties with a range of individuals, including both family and friends, where friendships were built on the connectedness that comes from sharing the same sexual identity (18). Other characteristics of men with high-quality networks included involvement in groups or spaces where they could not only be their authentic selves, but also find intimacy and support (18). Men in low-quality networks described the existence of homophobia and heterosexism within their collection of relationships, which resulted in hiding aspects of their true selves; this created barriers for intimacy and support (18). Furthermore, some men in this network type expressed a sense of obligation to their biological families, despite the negative sentiment this was associated with (e.g. the need to be “closeted” because of religious beliefs within the family) (18). Overall, participants across all network types did not consider their biological families to be central to their environments (18). Networks were mainly comprised of long-term friendships, and local groups were a source of interaction (18). Another study among aging gay men found that participants relied more upon family-of-choice networks opposed to biological family when help was needed (20). This survey among 26 aging American veterans who self-identified as gay, ranging in age from 50-92 (average age 64.3 years), also found that participants reported having a positive mental and physical health outlook on life, and their needs and experiences were similar to that of non-veterans (20). Generally, the group had less housing and economic security (20). However, most were self-sufficient, with the majority of the sample not needing any help with activities of daily living (20). Participants did note a lack of social support, with 53% desiring someone to talk to when feeling down (20).
As noted previously, the confluence of aging and sexual minority status is a developing area of research (2). One study from 2015 examined the social construct of “internalized gay ageism”, a term describing how ageism and homophobia may be jointly internalized in aging gay men (5). Authors posit that due to internalized gay ageism, midlife and older gay men may be exposed to unique sources of stress and as a result are at increased risk for mental health issues (5). From 2012–2013, data from a sample of 312 gay men in Los Angeles (mean age 60.7 years, range 48–78), who had been participating in the Multicenter AIDS Cohort Study since 1984–1985, were examined to determine if there was an association between internalized gay ageism and depressive symptoms (5). Authors found that internalized gay ageism was positively associated with depressive symptomology, independent of other factors, and concluded that internalized gay ageism is consequential to gay men’s psychological well-being (5).
A more recent study (2020) looked at what psychosocial and demographic factors have impacted internalized homonegativity among older gay and bisexual men specifically, noting that few studies have explored this (3). For example, in 2016 a systematic review on internalized homonegativity in sexual minorities found that across 201 studies among 77,663 participants, the average age was 33, despite the age range being from 11 to 94 (21). Internalized homonegativity refers to the process where sexual minorities internalize societal messages concerning gender and sex, which in turn influences self-image (21, 22). This study used data from 802 gay and bisexual men residing in South Florida who were over the age of 40, with an average age of 54.8 years (3). Psychosocial outcomes were measured using the Internalized Homonegativity (IH) Scale, the Coping Self-Efficacy Scale (CSES), and the Self-Silencing Scale (STSS) (3). Scores on the IH Scale were higher among participants who: were single, were less involved in gay community volunteering, experienced less coping self-efficacy, and reported higher levels of self-silencing behaviours (i.e. suppression of thoughts, feelings, or actions that conflict with others in order to maintain relationships) (3). Authors suggest that more programming tailored to midlife and older gay and bisexual men focused on contributors to internalized homonegativity is needed (3).
In addition to the previously discussed benefits of having a quality social network, other research has demonstrated that specific types of social support may be beneficial in reducing internalized homonegativity and sexual identity concealment (23). In a study from Australia, data was collected from a cohort of 186 gay men, aged 40 years and over, who took part in the final waves of a national survey on the health and well-being of older Australian gay men (23). The Internalized Negativity subscale of the Lesbian, Gay, and Bisexual Identity Scale (LGBIS) was used to measure internalized homonegativity, and the Concealment Motivation subscale of the LGBIS was used to measure sexual identity concealment (23). Three types of social support were examined: Appraisal Support (i.e. receiving emotional or psychosocial support), Belonging (i.e. sense of companionship or inclusion), and Tangible Support (i.e. having someone help with various tasks) (23). Authors found that at 12-month follow-up Tangible Support significantly predicted lower internalized homonegativity, while greater Appraisal Support predicted a lower propensity to conceal one’s sexual identity (23). Authors discuss that Tangible Support may be helpful in accomplishing goals, whether they be day-to-day tasks or goals of more significance; additionally, Tangible Support may send the message that an individual is valued enough to be a recipient of support (23). Appraisal Support may help gay men to feel safer about disclosing their identity, which may allow them to feel more comfortable or positive about their sexual identity, which could reduce motivation to conceal (23). Another metric that was measured was sources of social support, which found that receiving social support from the community or government agencies predicted greater levels of internalized homonegativity at 12-month follow-up (23). Authors note that this source of support was assessed broadly, and that generally, contact with some agencies may not always be a positive experience for aging gay men (23).
A 2020 study notes that literature on the experience of loneliness and social isolation among older individuals who identify as sexual minorities seldom distinguishes findings specific to gay men only (24). While social isolation among men who have sex with men has been discussed in a recent review (25), it appears that living alone is a vulnerability that can impact older gay men.
A 2016 study among 160 gay men in Australia between the ages of 65–92 (n=160) found that nearly one-third of the sample reported depressive symptoms that were clinically significant; specifically, living alone was associated with lower levels of belonging with gay friends (6). Authors concluded that a sense of belonging with gay friends was a protective factor for depression among older gay men who lived alone (6). However, another study from Australia among gay men over the age of 50 (n=242) found that living alone was not a significant predictor of psychological stress (26); rather, receiving emotional support appeared to play a greater role in the mental health of older gay men (26). This finding was noted in a 2020 study among Australian men aged 60–91 years (n=270), which interestingly found that age played a moderating role in the relationship between living arrangement and depressive symptoms (27). The study analysis found that gay men older than 66.28 years who lived alone were at increased risk of depressive symptoms compared to those who were younger, suggesting that this relationship strengthens with age (27). It should be noted that data for these studies was collected prior to December 9, 2017, when gay marriage was legalized in Australia. A U.S. study conducted the Baltimore Metropolitan area examined the needs and priorities of older Black men who have sex with men, aged 40–79 years old (n=91) to inform HIV prevention programming (28). A ranking indicated that top priorities included housing, financial stability, and physical health (28). In response to the question, “What do you want in a program?”, a few different needs were described. Participants wanted to: meet other Black men their age in a “safe space”, perhaps in the format of a drop-in centre where they could have discussions or play cards; gain information on finances, estate planning, HIV/AIDS education, employment; receive aid for mental health or coping; and be involved in programming that offered activities, especially for mature men (28). Finally, participants felt that they wanted to “give back”; that is, mentor young Black men who have sex with men in order to help the younger generation to learn from their mistakes and to teach them about safer sex (28). Authors noted that generally, there was a lack of settings in which older Black men who have sex with men could socialize and/or seek support in a non-sexual space (28).
Aging gay men living with HIV
Another area that should be mentioned is the experience of living with HIV as an aging gay man, as in addition to the stigmas associated with being gay and being older, these individuals may also experience stigma related to HIV status (7, 29). However, one study did find that gay or bisexual men living with HIV may be able to better cope with stigma from HIV when compared to heterosexual men living with HIV (30). Nonetheless, a study from 2020 notes that “[t]he dearth of research on older HIV-positive gay men’s experiences and needs, in the context of health care and social services, represents perhaps the most salient gap in the scholarship in this area” (16).
One study examined the experience of multiple stigmas in older gay men living with HIV in Alabama, Georgia, and North Carolina, and if these combined experiences had an impact on quality of life (7). The study used quantitative scales including the Internalized Homonegativity Inventory, the Internalized HIV Stigma instrument, the Ageism Survey, and the HIV/AIDS-Targeted Quality of Life instrument (7). There were 60 gay men living with HIV, between the ages of 50 and 65 (average age 54.6 years), included in the analysis; on average, participants had been living with HIV for 18 years (7). Authors found that within this older adults 50–65 age group, age was negatively correlated to homonegativity; that is, older gay men reported lower levels of homonegativity, which they explained by stigma competence, which is the development of skills necessary to overcome actual and perceived stigma experiences (7). Additionally, authors observed that those who reported higher levels of social support measures (i.e. emotional/informational support, affection, tangible support, and positive interaction) reported lower levels of internalized HIV stigma (7). Authors concluded that support groups specifically targeting older gay men living with HIV could have a positive impact on quality of life (7).
A 2020 qualitative study from Canada sought to conceptualize health and social service needs among 16 participants who identified as older gay men living with HIV (16). Participants were recruited from AIDS service organizations in Toronto, were aged 50 and older, and had received health care from doctors or nurses in the past 12 months (16). Questions in the semi-structed interviews were designed to facilitate discussion on experiences seeking and receiving care, perceived quality of care, and perceived service needs in the context of navigating care (16). A common finding in the study was that participants were often not recognized as having distinct experiences in health and social service systems, and as a result, their unique needs in areas such as employment, personal care, and mental health were not met (16). One participant noted that because of historical and ongoing invisibility across care systems, psychosocial needs among aging gay men living with HIV were often unmet (16). Another participant spoke to this theme, suggesting that his needs had evolved beyond that of HIV care (16). Generally, there appears to be a need for comprehensive, specialized support services (16). Specifically, having to forgo the participation in the labour market in order to qualify for HIV benefits was related to loss of socioeconomic stability and sense of purpose (16). Another important need was receiving assistance free of stigma and discrimination, whether it be for limitations or physical and cognitive declines associated with HIV (16). The theme of isolation was also prevalent, and as discussed in prior studies, participants experienced isolation stigma and discrimination from their families of origin, and also due to loss of partners (16). Authors suggest that existing capacities of older gay men living with HIV can be mobilized to develop and enhance services that address this population’s needs (16).
A study examining data from the 2014 Aging with Pride: National Health, Aging, and Sexuality/Gender Study of LGBT older adults from throughout the U.S. found that in a subsample of gay and bisexual men (n=335, aged 50 and older), social support and community engagement were positively associated with resilience and sense of self-efficacy (31). Some smaller, recent studies from Canada have explored similar themes that promoted resilience in this population. One small qualitative study from Ontario utilized semi-structured interviews to determine protective factors that fostered resilience to HIV/AIDS (32). Participants were 41 racially and ethnically diverse men who have sex with men, aged 40 years and older, who were meaningfully involved in various roles within the HIV community (e.g. peer researcher, advisory committee member) (32). Three major themes that promoted resilience were identified in the interviews: protective factors that had been previously “established” in academic literature, such as education, religion and spirituality, and social support; behavioural strategies that provided some level of protection against the clinical and social impacts of HIV/AIDs, such as compartmentalizing, serosorting, and volunteering; and other protective factors such as abstinence, managed substance use, meaningful sexual relationships, and paradoxically, trauma from the HIV/AIDS epidemic (32). Regarding trauma as a protective factor, authors explained that “…some participants consider[ed] the recognition of such traumatic loss as a protective factor that could be utilized as a strong motivation for fiercely working toward the goal of ending the HIV/AIDS epidemic, and thus, an impetus for fostering their HIV resilience” (32). Authors note that valuing these protective factors could be used to develop interventions, services, and programs that aim to foster resilience (32). Authors conclude that when developing interventions to address health disparities related to HIV/AIDS among older men who have sex with men, it would be beneficial to value the factors this study identified as protective against the impacts of HIV/AIDS (32). A second publication using the same data from the above study identified four personal strengths that fostered resilience to HIV/AIDS: proactiveness, perseverance, having the right mindset, and self-awareness with self-control (33). Proactiveness referred to researching what was known about HIV/AIDS at the time of diagnosis, seeking out gay-friendly healthcare providers, and exploring services and support groups; perseverance was described as the determination to get better and stay healthy, a mentality to “not only survive but thrive” (33). The third protective factor, having the right mindset, varied among participants, but generally complemented proactiveness and perseverance (27). Finally, self-awareness with self-control was not a theme that was specifically mentioned, but was alluded to when participants spoke of curbing substance use, managing alcohol consumption, and selecting sexual partners (33).
Factors that may impact local applicability
Most studies included in this review were conducted with a small number of participants, so results may not be generalizable to the larger population of aging gay and bisexual men. Additionally, some studies included in this review examined populations that were described as middle-aged and older (i.e. men aged 40 and up); a gay male in his mid-40s would probably have different psychosocial vulnerabilities and needs compared to a gay male who is approaching 80 years of age. Thus, caution should be taken when interpreting the results.
What we did
We searched Medline (including Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE® Daily and Ovid MEDLINE®) using a combination of (terms [gay or bisexual or men who have sex or MSM or gbMSM or queer or sexual minority or LGB*] in titles or abstracts or MeSH term Sexual and Gender Minorities) AND terms older or aging or ageing or aged or senior* in titles or abstracts. Searches were conducted on September 9, 2021 and results limited to English articles published from 2015 to present. Studies from low- and middle-income countries were excluded. Reference lists of identified articles were also searched. Google (grey literature) searches using different combinations of these terms were also conducted. The searches yielded 2,080 references from which 33 were included.
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Rapid Response Service. Psychosocial needs and vulnerabilities of older gay and bisexual men. Toronto, ON: The Ontario HIV Treatment Network; October 2021.
Danielle Giliauskas and David Gogolishvili