Stress and Mental Health Among Midlife and Older Gay-Identified Men

Objectives. We investigated associations between stress and mental health (positive affect, depressive symptoms) among HIV-negative and HIV-positive midlife and older gay-identified men, along with the mediating and moderating effects of mastery and emotional support. We also studied the mental health effects of same-sex marriage.Methods. We obtained data from self-administered questionnaires completed in 2009 or 2010 by a subsample (n = 202; average age = 56.91 years; age range = 44–75 years) of participants in the University of California, Los Angeles component of the Multicenter AIDS Cohort Study, one of the largest and longest-running natural-history studies of HIV/AIDS in the United States.Results. Both sexual minority stress (perceived gay-related stigma, excessive HIV bereavements) and aging-related stress (independence and fiscal concerns) appeared to have been detrimental to mental health. Sense of mastery partially mediated these associations. Being legally married was significantly protective net of all covariates, including having a domestic partner but not being married. Education, HIV status, and race/ethnicity had no significant effects.Conclusions. Sexual minority and aging-related stress significantly affected the emotional lives of these men. Personal sense of mastery may help to sustain them as they age. We observed specific mental health benefits of same-sex legal marriage.Classic conceptualizations of social stress theory1–3 posit that social stressors—socioenvironmental demands that tax or exceed individuals’ adaptive capacities or block the attainment of sought-after ends—can be harmful to health, particularly to mental health. Through the stress process, stressors rooted in critical social roles or relationships are conceptualized as primary sources of subsequent difficulties that collectively diminish well-being.3,4 Psychosocial resources that regulate the health impact of stress, such as social support and sense of mastery, are key elements of the stress process because they may disrupt the relationship between stress and distress.1,5Minority stress theory6–8 contends that minority populations also can be exposed to unique stressors that create strains on individuals as they attempt to adapt and function in their everyday environments, which in turn negatively affect well-being. Investigators have found compelling evidence of the negative impact of minority stress on mental health among sexual minority persons, who consistently demonstrate higher rates of mental disorder, substance misuse, suicidal ideation, and deliberate self-harm than heterosexual populations.8–14However, few studies have examined social stress, minority stress, and health among midlife and older sexual minority persons. Such studies are of public health significance because the baby boomer cohort quickly is approaching old age, and embedded in this cohort are midlife and older sexual minority persons who endure common aging-related stressors in addition to the unique challenges that are associated with their sexual minority status.8,13,15,16 These challenges include well-established domains of minority stress associated with stigma, discrimination or prejudice, internalized homophobia, and concealment.8,13 Other stressors include exclusion from legal marriage, limited legal rights for same-sex partners, lack of access to informal care within traditional family networks, insensitivity to sexual minority health issues among care providers, and ostracization in health care and long-term care settings.17,18Midlife and older sexual minority persons also are of particular interest because of their life-course experiences of either being socially invisible during most of the 20th century or of coming of age on the heels of the gay rights movements in the 1960s. They are the first sexual minorities in history to age with an identity that is now socially and politically recognized as they become increasingly enfranchised. A review of the literature on sexual orientation and aging offers further insight into the life-course challenges faced by the estimated 1 to 3 million older sexual minority adults in the United States—a number that is increasing dramatically.19 Within this broad cohort of midlife and older sexual minorities, gay-identified men (hereafter, gay men) are unique because of their additional historical experience of having been in the highest HIV/AIDS risk group when virtually nothing was known about HIV transmission routes, making prevention impossible. The profound impact of the AIDS epidemic on the lives of these men cannot be overstated.19 For example, they have outlived many of their peers lost during the early years of AIDS,20 diminishing their social support networks.21We examined sexual minority stressors8,13 and generally applicable stressors associated with aging22,23 as well as their hypothesized associations with mental health (Figure 1). On the basis of social stress theory1–3 and its empirical operationalization with the elaboration model,24 we also examined the role of psychosocial resources as “third variables” that are hypothesized to offset these associations. Psychosocial resources may mediate or moderate the association between stress and mental health.1–3Open in a separate windowFIGURE 1—Hypothesized associations between social stress and mental health among midlife and older gay-identified men.In this case, mediation occurs when stress influences a psychosocial resource, which, in turn, influences mental health, thereby transmitting the effect.24,25 Moderation occurs when the effect of stress is contingent upon a psychosocial resource (the dashed line in the center of Figure 1) meaning that its effect differs across various values of the psychosocial resource. We controlled for the effects of background factors that may influence observed findings, with a particular focus on relationship status. We chose this focus because research on same-sex marriage and mental health among gay men is virtually nonexistent despite evidence of the ameliorative effects of marriage on mental health among heterosexual persons.26By investigating associations among these key constructs, we sought to broaden understanding of the stress and aging experiences of midlife and older gay men, many of whom enter later life at increased risk for HIV infection or chronic HIV-related comorbidities,27–29 suicidal thoughts or behaviors,12,30 and other health- and disability-related difficulties.31