My essay “Mature Gay and Bisexual Men and Suicide” in Psychology Today drew these questions from a reader: What drew you to psychiatry? Why the interest in suicide in mature gay and bisexual men? What accounts for their high rates of suicide and mental health issues, and are the rates different among younger gay and bisexual men? How does race factor into this? What can be done to combat high rates of suicide among mature sexual minority men?
I have always thought of psychiatry as a calling rather than a choice. To be successful, one must be able to accurately empathize with patients’ emotional pain. Our training allows us to step back from that pain 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.
As 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 led to my interest in what the Centers for Diseases Control and Prevention (CDC) calls “men who have sex with men,” or MSM. This category was created when the CDC sought to expand its education to all men at risk for transmitting HIV and other sexually transmitted diseases to incorporate not just gay-identified men but also those who are straight-identified but still have sex with men.
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, but not all, MSM experience significant emotional pain about this conflict, and suicide rates are highest when they face the predicament of making a decision to come out or remain closeted. An Australian psychiatrist has proposed the term “predicament suicide” to describe the choice to end one’s life in the absence of any mental illness when caught in just this sort of predicament.
When I considered coming out, I felt I had two choices: remain married and potentially betray my wife by having clandestine sex with men, or betray my wife and children by leaving. (For a more in-depth account, see my article “I Didn’t Want to Betray My Wife Again.”) 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 a decision about coming out, we tend to imagine 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.
Many of the men I work with are older and often married. Many love their wives and children and abhor the thought of hurting them. Suicide begins to look like a rational choice, even though of all the options, it is the one that would hurt others the most.
Age is a factor that adds to this conflict. 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. Few examples of people living that life were available to us. Many MSM are not 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 are higher than for young men, and for gay and bisexual men, they are even higher—but not as high as they are for young men making the decision about coming out.
Studying the rates of suicide in bisexual men is complicated because bisexuality lacks a consistent definition. Many people, for example, who behave in bisexual ways (MSM) may not have self-identified as bisexual. Likewise, people can identify as bisexual regardless of sexual experience.
It’s important to note that behavior is “what I do”; identity is “who I am.” Sexuality is a complex and evolving combination of sexual fantasy, sexual attraction, and sexual behavior. These are not constant from one individual to the next and may not be consistent even within the same person.
Race is another factor that contributes to the stress and pain of the coming-out predicament. Some in the media have discussed “minority stress,” suggesting that the LGBTQ community of color has a dually stigmatized identity. However, there are no studies showing a greater incidence of mental illness in this group than in the general population. Some people in the Hispanic community have an additional stress due to their immigration status, which may lead to greater distress for them. People of color are also apt to experience greater difficulty in deciding to come out because often their communities have very strong family values.
We are currently witnessing a crisis of female-to-male trans people being murdered. A large number of these men are members of racial minorities, where a macho culture continues to prevail.
In all LGBTQ communities, suicide rates go down when acceptance of LGBTQ men and women 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. (If you need to find a supportive counselor, the Association of LGBTQ Psychiatrists has a referral directory.) What is clear is that our stories are what change minds; statistics will never do that.