Ask the Doc
Before he came out, Dr. Olson had many questions but didn’t know whom it was safe to ask. He welcomes your questions and comments about your sexual identity, coming out, sexual functioning as men age, relationships, and how to face aging with optimism rather than dread. Although he will respond to your questions, his responses are not to be considered medical advice. Feel free to write him at email@example.com with your comments and questions on any of these or related topics.
Delving Deeper into the Issue of Suicide among Mature Gay and Bisexual Men
The following questions were submitted by a reader in response to my Psychology Today article titled “Mature Gay and Bisexual Men and Suicide“:
Q: What drew you to a career in psychiatry?
A: I have always thought of psychiatry as a calling rather than a choice. I think it is essential that one knows what emotional pain feels like to be successful. It is necessary to be able to empathize with patients, and our training allows us to step back from that and then apply some objective, rational thought as to the most appropriate intervention. Healing occurs through genuine warmth, accurate empathy, and unconditional positive regard for each patient.
Q: What drew you to investigating suicide in mature and gay and bisexual men?
A: I suppose the best answer is that I am a mature gay man myself, and as someone who did not come out until I was forty years old, I went through a time of transition when I considered myself bisexual. This has drawn me to an interest in what the Centers for Diseases Control and Prevention (CDC) calls men who have sex with men, or MSM.
This category was created because of the large number of men who behaviorally have sex with men while at the same time do not wish to be labeled as gay or bisexual. As many as 10 percent of men have sex with men, while only about 4 percent of the male population identifies as gay or bisexual. Many of these men experience significant emotional pain about this conflict, and suicide rates are highest as they face the predicament of making a decision to come out or remain hidden.
Q: What accounts for high suicide rates and risk for mental health issues among mature gay and bisexual men?
A: A predicament is a situation in which there is no good choice. One is faced with two or more possible choices, but all the choices are less than optimal. For example, when I considered coming out, I felt I had two choices: remain married and potentially betray my wife by having sex with men on the side, or betray my wife and children by leaving. It was clear to me that I could not contain my attraction to men, so abstinence from sex with men was a choice that I knew would end in failure. I had to choose what for me seemed like the “least worst” option.
In considering these decisions, we tend to make the potential losses greater than they are, and there is no way to understand the possible gains one experiences from leading a self-actualized, wholehearted life.
An Australian psychiatrist has proposed the idea of predicament suicide. It is a choice to end one’s life in the absence of any mental illness when caught in just this sort of predicament.
Many of the men I work with are older and often married. Many love their wives and their children, and the thought of hurting them is abhorrent to them. Suicide begins to look like another choice, even though most of us would agree that of all the options, it is the one that hurts others the most.
Q: How does age factor into this? Are the rates of suicide and mental health issues among younger gay and bisexual men, and mature gay and bisexual men different?
A: Age is an issue for the reasons I just mentioned. Among older gay men, marriage was an expectation, and the thought of living in a loving, long-term relationship with a man wasn’t even a consideration. So few examples of people living that life were available to us. Many of these men are not “serial monogamists” or men looking only for “one-off” quick sexual satisfaction. They want the emotional and physical intimacy that can only be enjoyed in a long-term relationship.
The rates of suicide for men in midlife in general are higher than for young men, and for gay and bisexual men, they are even higher.
Q: Is there a difference in rates of suicide and mental health issues between gay men and bisexual men?
A: I don’t have an answer to this question since I have not seen data on it. The issue of bisexual men is complicated because bisexuality lacks a consistent definition, and many who behave in bisexual ways (MSM) may not have self-identified as bisexual. This lack of clarity about the definition of bisexuality will make it difficult to study the issue. The bisexual community complains of “bisexual erasure,” meaning their sexuality is often left out of the LGBTQ equation, but I think it’s because that clarity is not there, making it difficult to find a study group that is not overly diverse.
It’s important to note that behavior is “what I do”; identity is “who I am.” Others may try to define us by what we do, but all of usas individuals know what we think and choose how to define ourselves. Sexuality is a complex and evolving combination of sexual fantasy, sexual attraction, and sexual behavior. These things are not constant from one individual to the next and are not even consistent within the same person. If heterosexuality is on one end of a spectrum and homosexuality is on the other, bisexuality falls somewhere in the middle. But where? Some who call themselves homosexual, for example, have attractions to and fantasies about the opposite sex, and in one study, nearly 10 percent of “heterosexual” men were having sex exclusively with men.
Someone who has had sexual experience with or even just an attraction to people of more than one sex could be considered bisexual, but the individual may not identify that way. Likewise, one can identify as bisexual regardless of sexual experience. Furthermore, identities can change over time. Definitions can change too.
When the CDC sought to expand its education to all men at risk for transmitting HIV and other sexually transmitted diseases, it began using the term “men who have sex with men,” or simply “MSM,” to incorporate not just gay-identified men but also those who are straight-identified but still have sex with men. Women who have sex with women (WSW) do not have the same risks as MSM, so the term is much less commonly used.
Q: How does race factor into this?
A: Some writers have discussed “minority stress,” suggesting that the LGBTQ community of color has a dually stigmatized identity. On the other hand, other studies show that there is no greater incidence of mental illness in this population. Some people in the Hispanic community have an additional stress due to their immigration status, which may lead to greater distress for them.
One final factor contributes to the difficulty that people of color experience, and that is that often their communities have very strong family values, increasing the pain of the coming-out predicament.
We currently face a major health crisis in the number of female-to-male trans people being murdered. A large number of these men are in racial minorities, where a macho culture continues to prevail.
Q: What can be done to combat high rates of suicide among mature sexual minority men?
A: Suicide rates go down when acceptance is high. The challenge, albeit a big one, is to work toward greater acceptance of members of the LGBTQ community. In a macro-social sense, we have moved in that direction, but at the micro-social level (i.e., the individual level), the choice to come out can be very difficult. No universal rules exist for deciding to come out. Each person must contemplate the risks and benefits and then make the choice with inadequate information.
What is clear is that our stories are what change minds; statistics will never do that. Not everyone can be completely out and proud. We may choose to be out in some areas of our lives but not in others. Many of us have found that the losses we experienced in coming out were much less than imagined, and the reward greater than imagined, but there are no guarantees.
When I’m with a Woman I Want a Man
Q: I am a male in my 40s and have only explored being sexual with men for about five years. I have a strong attraction to fit muscular men, but also have a strong attraction to soft and sensual women. It seems that when I am in a relationship with a man, I think about what I am missing with a woman and vice versa. I’m searching for a way to find happiness within myself so that I can project it outward and attract the right person for a long-term relationship.
A: I think your comment is a fairly representative one from someone who is bisexual. But this kind of conflict exists for people who are gay and straight as well. When we have committed to a relationship, that does not disconnect our attraction to others. We may still have powerful sexual urges to be with someone else.
In economics, there is a theory called the Prospect Theory: when confronted with a decision where the risks and outcomes are both unknowable, we must decide based upon a satisfactory solution, not an optimal one. If you wish to find a monogamous relationship, you will need to shut down a response to those urges to have a sexual relationship with someone else. Granted, that isn’t easy to do.
Of course, one can find exceptions. Some people live in committed relationships that allow a certain amount of openness in responding to sexual attraction to another person. Each couple can and must make their own rules, but what is critical is honesty in the relationship to keep from betraying the other person’s trust.
All relationships require a certain amount of sacrifice, and not just in the area of sex. If you’re unwilling to make sacrifices, perhaps you’re not ready for a relationship, although your comment suggests that you are. In that case, it means either sacrificing something you want or finding someone who will accept that you might also be drawn to someone of the opposite sex.
Honesty is paramount, but you will find that some people are unwilling to accept the duality of your sexual attractions.
Finally Out: Letting Go of Living Straight is available wherever you buy books or on Amazon.
Click this link for information about men’s sexuality across the lifespan.
(This article was previously published on Psychology Today.)
Contributors to Depression in Mature Gay Men
After I wrote “Why Older Gay Men Are Attempting Suicide at a Higher Rate,” I received a couple of poignant responses. BWrigth, age 65, revealed his personal struggles, which included his dilemma about whether to come out to his parents; the loss of his business, his home, and his health insurance; and several health challenges, including serious side effects from the medications he had been prescribed. He said that he had “not ruled out” suicide but doesn’t want to hurt his family or close friends. Michael O’Hanlon, a 60-year-old gay man from Australia, wrote about feeling invisible—even among close gay friends who are younger—and suggested that depression in mature gay men could be linked to rejection and ageism in the gay community. Here’s how I responded to them.
I want to respond to the previous posts from BWrigth and Michael O’Hanlon because they bring up important topics that I have been asked about many times. Neither of you are at all unique in what you have experienced.
When I turned 60 years old, I also went through a difficult time for some of the same reasons you’ve mentioned. I had lost my mother, my stepfather, and a brother within six months, and some friends had died. I needed a knee and a shoulder replacement. My career had plateaued, and I thought it was on the decline. I had some difficulty with erectile dysfunction. All I could see for the future was a series of continued losses.
Then after I gave a speech in Houston, a man raised his hands in the air and said, “I’m 82 and this is the best time in my life.” I thought, What does he know that I need to know? One of my favorite sayings (sometimes attributed to Buddha) is “Pain is inevitable; suffering is optional.” In other words, I couldn’t change the fact that I was sixty and that I had experienced many losses, but I was suffering because that was all I could think about. I began to refocus my thinking on age as an adventure with opportunities I had never had and may not have again.
One of the “opportunities” is the power to reshape our thinking. We can deconstruct an old, outdated value system and develop a new one consistent with the person we believe that we are, not one based on others’ expectations of us. I wrote about it in this essay in Psychology Today.
Sometimes we think of coming out as an event, but it is a process. I don’t believe we must come out to everyone in every circumstance. Being honest about our sexual orientation is liberating for us personally, but it can damage relationships that are important. BWrigth, since you’re 65, your parents must be in their 80s. They lived in an era when gay men and women were sent to prison and considered deviant and predatory. Coming out to them may have unintended consequences for them and for you. I appreciate your wish to be honest with them; they may even already suspect it. But once it is out in the open, it demands a response, and you have no control over what that response might be. You have been considering this for years; they only just would begin to think about it.
In considering a decision like this, where risks and outcomes are uncertain, we tend to magnify the negative and minimize the positive. It is certainly possible that your parents might respond, “We love you anyway you are.” But there is no guarantee. No optimal decision exists, but each of us must decide for ourselves what is a satisfactory resolution, how far and to whom to come out. You have already experienced a lot of losses. Do you wish to risk the loss of your parents’ support at a time when you really need some?
Financial and medical problems are one of the major sources of difficulty for us as we grow older. I’ve been both poor and financially secure, and I can tell you that financial security does not guarantee happiness. I am absolutely convinced that happiness during our later years depends primarily (after our basic needs are met) upon having something that gives our life meaning and having friends (gay or straight) who accept us as we are.
Doctors are just people and we are as diverse as the rest of the population. Two things are critical: that they are well-trained and that you feel you connect with them. Men talk about their depression less than women do, but a good doctor is one place to start. All medications have risks, and the more meds you take, the higher the risks. A doctor cannot possibly remember all the drug interactions and less frequent side effects. Patients must advocate for themselves. A good place to check for drug interactions can be found here. I refer to it frequently when I treat patients. Having a companion go to your medical appointments with you will also result in better medical care.
Many of the things you mentioned, BWrigth, are considered “nonspecific symptoms,” meaning they could be attributed to many things. Depression could account for some, medications for others. And there are other possibilities as well. This can make treating them somewhat complicated, but treatment is possible once the causes are discovered.
Struggling with prostate problems and erectile dysfunction (ED) are indeed a potential curse/pain, but don’t suffer needlessly. See your doctor about the prostate problems. While medical problems and medications can cause some of the problems related to ED, often the problems are psychological, too. At the first sign of some difficulty with erections, men often begin to worry that they are losing their ability to function sexually, and then the worrying about the problem becomes an even bigger problem. I have addressed this in my Finally Out Tips. But important research shows that while sex drive, ejaculation, and erections may diminish as we age, sexual satisfaction can remain constant. The important message is that good sex does not demand that we have a world-class erection!
Suicide sometimes begins to seem rational when we’re faced with a serious predicament, but it is a permanent solution to what in most cases is a temporary problem. I can’t tell you what the solutions are, BWrigth, but I can tell you that I believe there are solutions, although sometimes finding them can be painfully slow.
Having the right persons to talk to is critical. Your primary care physician can be a good one, but it is important that your doctor accept your sexual orientation. If your doctor doesn’t know or doesn’t accept your sexuality, he/she will give you bad advice. Here is a resource for finding a supportive health-care provider. Younger physicians may be more open and affirming about sexual orientation, but not necessarily. The same things hold true for finding a supportive counselor. The Association of LGBTQ Psychiatrists also has a referral directory.
Michael, most of us who are older have had the experience of either feeling we were sitting on the sidelines in the LGBTQ community or have been invisible to them. For many of us, dancing the night away and drinking excessively has lost its charm. We need gay spaces where we can talk together and hear each other. Many larger communities have options for that. One international organization that provides these opportunities is Prime Timers Worldwide, with about 80 local chapters; it also has an independent group for those who live too far away from chapters. Another online resource to find connections is on Facebook, which also might be a good place for you, BWrigth, to find someone to chat with.
I would also like to try to dispel a myth about younger/older men. Not all young gay men who like older men are looking for a “sugar daddy” to take care of them, and not all older men who like younger men are looking for a “trophy partner.” Age can be a factor in sexual orientation. I would take exception to your young friend’s statement that “younger faeries often band together to defend themselves from unwelcome sexual attentions from older faeries.” Older gay men are not predators, at least the majority, and young gay men have nothing to protect themselves from; my husband is fifteen years younger than me, and we’ve been together for thirty years. And many younger men who like older men prefer to be in the presence of older men; as one said to me, “I like older men because they have rounded corners.” We do have a bias in our culture and a focus on youth, but part of that is because those of us who are older have not raised our voices and said, “Hey, I’m queer, too. Notice me!”
Gay, straight, or other, ageism is a factor because of stereotypes. Stereotypes exist in a world of “those other people.” They exist when one outside group attempts to define another. One characteristic of the “other” is elevated to master status and generalized to an entire population; it is the basis of all prejudice. But we are also the victims of those stereotypes because we have internalized them, too. If we believe that as older gay men and women we’re in a period of decline to nothingness, we are our own victims of the stereotype.
I am 74 now. When I was young, 74 was considered very old. But now I am considered a survivor, and I have a life expectancy of another 12 years. I feel an urgency of time, but it allows me to choose to do things I really want to and not do other things that I once thought I had to do. I have moved things from my bucket list to an un-bucket list. I no longer feel pressured to climb the ladder to the top. I don’t go to cocktail parties unless I know I’m going to like the people who are there. I don’t need to “network,” to find people who can move me further up the ladder. I don’t sit through boring lectures. I don’t read lengthy essays unless they really have something important to say. I hope you’re still reading this one. Make this the best time in your life.
Finally Out: Letting Go of Living Straight is available wherever you buy books or on Amazon.
Click this link for information about men’s sexuality across the lifespan.
(This article was previously published on The Doctor Weighs In.)