Arts Social Sciences Centre for Social Research in Health

‘Comfortable in my own skin’ Stigma, mental health and wellbeing among married men who have sex with men

Max Hopwood, Carla Treloar, John de Wit April 2017 Centre for Social Research in Health UNSW Sydney NSW 2052 Australia T +61 (2) 9385 6776 F +61 (2) 9385 6455 E [email protected] W csrh.arts.unsw.edu.au

© UNSW Sydney 2017

Suggested citation Hopwood, M., Treloar, C., & de Wit, J. (2017). ‘Comfortable in my own skin’: Stigma, mental health and well- being among married men who have sex with men. Sydney: Centre for Social Research in Health, UNSW Sydney. Acknowledgements The authors would like to acknowledge the men who participated in this study. We sincerely appreciate the time and effort that you made available to us for an interview. Thank you to Steven Bloom, President of the NSW Gay and Married Men’s Association (GAMMA NSW). The study was funded by Beyondblue and was conducted by the Centre for Social Research in Health in partnership with the Victorian AIDS Council (VAC), ACON, and GAMMA NSW. The Centre for Social Research in Health is supported by a grant from the Australian Government Department of Health.

Centre for Social Research in Health I ‘Comfortable in my own skin’: Stigma, mental health and wellbeing among married men who have sex with men Contents

Executive summary 1 Introduction 4 Method 5 Participants 5 Outline of main themes 7 1. Compulsory heterosexuality: ‘Jack, you can’t be a hairdresser’ 7 2. Poor mental health: ‘That’s why young men kill themselves’ 8 3. Coping in a mixed orientation marriage: ‘It was sort of like going to the movies’ 11 4. Coming-out gay/bisexual: ‘It was not something she could make herself prettier’ 14 5. Current wellbeing: ‘I feel humbled by the journey that I’ve had’ 16 Conclusion 19 References 21

Centre for Social Research in Health II ‘Comfortable in my own skin’: Stigma, mental health and wellbeing among married men who have sex with men Executive Summary

Study aim This study aimed to explore the experience of married men who have sex with men (MMSM) in managing their sexual identity in everyday life and their experience of stigma, depression and anxiety.

Method In-depth, semi-structured telephone interviews with 16 MMSM from Queensland, New South Wales (NSW), Victoria and Tasmania were conducted between September 2015 and October 2016. Interviews were audio-recorded and data were thematically analysed.

Findings The main themes identified in these data are:

1. Compulsory heterosexuality The stigma of homosexuality and the disciplining effects of heteronormativity on gender and sexual identity formation during childhood, adolescence and early adulthood taught study participants to ‘see’ straight, to ‘read’ straight and to ‘think’ straight. Families, schools, sports clubs and churches were the structural mediums through which transgenerational homophobia and heterosexism were communicated and enacted. Men tried to emulate heterosexuality by marrying to avoid stigmatisation and to ‘fit in’ with the dominant social-relational landscape.

2. Poor mental health Participants reported a wide range of psychological and emotional conditions, including internalised stigma. Internalised stigma often shaped men’s sense of esteem, their attitudes and their practices, and was a barrier to good mental health. Participants reported depression, anxiety, suicidal ideation, attempted suicide, panic attacks, irrational thinking, insomnia, episodes of acute paranoia, feelings of isolation, anger at society, self-harm, and mental anguish about abandoning children. Guilt, feelings of sexual inadequacy, cognitive dissonance and confusion about the nature of sexuality were commonly expressed.

Centre for Social Research in Health 1 ‘Comfortable in my own skin’: Stigma, mental health and wellbeing among married men who have sex with men Executive Summary

3. Coping in a mixed-orientation marriage Coping with the demands of mixed-orientation marriage encouraged the compartmentalisation of sexual attraction and sexual behaviour, which operated at both an individual and social level. At an individual level, compartmentalisation allowed conflicting ideas about oneself to co- exist, and at a social level, heteronormativity compartmentalised sexual identity into the straight-gay binary whereby all married men are assumed to be heterosexual. By emphasising a distinction between love and sex, participants could integrate same-sex attraction and behaviour into their married lives. Sex with men was viewed, and practiced, as episodic, casual, anonymous and emotionless, and therefore represented no threat to their marriage. Compartmentalising sexuality was both adaptive and maladaptive; it enabled men to explore their sexuality, yet the stress of managing disparate sexual identities created the conditions for the development of internalised stigma and shame, and exacerbated feelings of anxiety and depression. Further approaches to managing the stress included the use of alcohol, anti-depressant and anti-anxiety medications, support via friendship networks, professional counselling, emotion- focused coping strategies such as denial, work, travel, and attending formal support groups.

4. Coming-out as gay or bisexual Mental health and wellbeing were significantly improved by coming-out as either gay or bisexual, despite this being an acutely stressful event in the lives of most participants, and in the lives of their wives and families. Coming-out was often partial and provisional; it meant being open about one’s sexuality only within the family, or among family and close friends. Participants wanted to maintain control over disclosure, often to protect adolescent children from the risk of homophobic bullying. Coming-out meant that the compartments participants had constructed to separate their private persona from their public married life could be dismantled, and an integrated self could begin to emerge. Participants who came-out perceived a change in their social status (i.e., they noticed a ‘subtle discrimination’ for identifying as gay or bisexual).

5. Current wellbeing Current wellbeing was affected by the influence of heteronormativity, past response to poor mental health, the effectiveness of problem- and emotion-focused coping strategies, and the experience of coming-out and finding a same-sex partner. Reports of current wellbeing varied widely and often depended upon the time since coming- out or the time since marriage separation; men who had come-out years earlier were more likely to report better current wellbeing. Wellbeing was enhanced by the resolution of conflict within the marriage, by reaching

Centre for Social Research in Health 2 ‘Comfortable in my own skin’: Stigma, mental health and wellbeing among married men who have sex with men Executive Summary a mutually agreed decision to separate or divorce, through negotiating an equitable distribution of family resources, and by establishing ongoing positive and mutually satisfying contact between family members. In retrospect, some men were grateful for the opportunity for personal growth and the outcomes they had achieved from a mixed-orientation marriage.

6. Conclusions and recommendations Interventions need to challenge the basic tenets of heteronormativity and compulsory heterosexuality to promote gender and sexual diversity. MMSM require access to resources (including innovative online resources) with information about mixed orientation marriage and referrals to appropriate support services such as counselling for gay and bisexual men. Resources may be discreetly targeted at traditional men’s publications, such as print and online sporting magazines, to reach the affected population. Workforce development programmes are needed to familiarise and upskill mental health professionals about sexuality-based issues, including mixed-orientation marriages. Further studies of mixed orientation marriage, including the perspectives of women and children, are needed to understand the effects on mental health and wellbeing of families.

Centre for Social Research in Health 3 ‘Comfortable in my own skin’: Stigma, mental health and wellbeing among married men who have sex with men Introduction

The size of the population of married men who have sex with men (MMSM) is difficult to determine. Estimates published in 2011 indicate that the population of Australian men who have sex with men (MSM) is 190,000 (United Nations, 2011) and in a national study of MSM (Rawstorne et al. 2008), 8% reported that they currently lived with a female partner. Generalising this proportion to the estimated size of MSM population in 2011, plus adjustment for population growth, it is estimated that more than 17,000 men in Australia are sexually attracted to men but are currently in relationships with women. In a comprehensive literature review of the sexual behaviours of MMSM, Hudson (2013) reports that the research literature on mixed orientation marriage to date is mostly about: why MMSM choose to marry and why heterosexual women remain married after husbands disclose their sexual orientation; the coping mechanisms and adjustment modes of MMSM and their wives; and the sexual behaviours of MMSM. To date, there are no data that specifically estimate the number of MMSM who have experienced anxiety, depression or suicidality and related stigma. Similarly, while there is some clinical and anecdotal literature on psychological issues among people in mixed orientation marriages (Hudson, 2013), there is little theoretically informed qualitative literature that engages with the lived experience of stigma and mental health among MMSM. While lesbian, gay, bisexual, transgender, and intersex (LGBTI) people are at increased risk of a range of mental health issues including depression, anxiety disorders, self-harm, suicidal ideation, and suicide (Carman, Corboz, & Dowsett 2012; Couch et al, 2007; Hillier, Edwards & Riggs 2008; Hillier et al. 2010; Ritter, Matthew-Simons, & Carragher 2012), there is very little research into these issues among MMSM. Various sources place the rate of suicide attempts for LGBTI people as being between 3.5 to 14 times higher than the rate for the general population (Bagley & Tremblay 1997; Garofalo et al. 1998; Herrell et al. 1999; King et al. 2008; Nicholas & Howard 2002; Remafedi et al. 1998). There is a need for further research of mental health, including suicidal ideation and suicide attempts, among MMSM. This project aimed to explore the experiences of MMSM for incorporation into a larger project to provide online resources to address issues of stigma, depression and anxiety. This interview-based study is one of the first to explore these issues in the wider context of gay and bisexual married men’s lives.

Centre for Social Research in Health 4 ‘Comfortable in my own skin’: Stigma, mental health and wellbeing among married men who have sex with men Method

Researchers aimed to recruit a diverse sample of MMSM through the organisation GAMMA NSW (NSW Gay and Married Men’s Association), which is in inner-Sydney. To encourage participation in the study, a banner was placed on the website of GAMMA NSW advertising the study and providing study contact details. At around the same time, a researcher (MH) from the Centre for Social Research in Health (CSRH) attended one GAMMA NSW evening session to promote the study and to encourage volunteers to participate. Recruitment commenced in late September 2015 and proceeded until October 2016. A first wave of recruitment led to 10 volunteers coming forward, and a second wave several months later led to a further six men volunteering. A semi-structured interview schedule was developed from a review of the literature. Interviews were conducted via telephone, lasted for between 45 and 90 minutes each, were digitally recorded, transcribed verbatim and cleansed of all identifying features, ready for thematic analysis.

Participants In all, 16 MMSM were interviewed via telephone, with the sample comprising men living in Queensland, NSW, Victoria and Tasmania. All participants, except for one man from the United Kingdom, were born in Australia from the 1940s through to the 1970s, in urban, rural and regional areas, and all were white, working- or middle-class men. Table 1 presents an overview of study participants. There was a mix of currently married, separated and divorced men. All 16 participants had come-out to their wives and children, and some to friends, workmates and employers: most had come-out from between 10 and 25 years prior to being interviewed, with five men having come-out since 2010. Therefore, all interviews are retrospective accounts of participants married lives however one account of coming-out and separation occurred as recently as 2015.

Table 1: Sample characteristics (n=16)

Age range in years 38–68 Current sexual identity n Gay 11 Bisexual 5 Current marriage status Separated/divorced 13 Remain married 3 No. of children - range 1–3 Years married - range 7–33

Centre for Social Research in Health 5 ‘Comfortable in my own skin’: Stigma, mental health and wellbeing among married men who have sex with men Method

Mostly, participants were not gay community attached (Chapple et al, 1998), that is they did not live in large urban gay communities, but instead were born, raised and often still lived in rural, regional and suburban areas across the four states. Several participants had moved to one of the inner-city gay communities in these states since their marriages had ended. Participants who volunteered to give an interview were assigned a pseudonym. No payment was given for involvement in the study. The study received ethical approval from the UNSW Human Research Ethics Committee.

Notes on the interviewing process As a qualitative method for collecting data, telephone interviews have advantages and disadvantages; one disadvantage from the point of view of the researcher is a reduced ability to verify participants’ reported bona fides, as they might not be who they claimed to be. Other disadvantages, that affect both the researcher and the researched, include the loss of visible indicators such as body language and facial expressions, which can further inform the analysis or alert researchers to participants’ distress or discomfort during interviews of a sensitive nature. Conversely, telephone interviews are convenient (for participants and researchers), low cost, and relative to face-to-face interviewing, anonymous. Arguably, in-depth interview data are enhanced by the intimacy and intensity produced by employing one channel of communication (i.e. voice). Regarding the identification and management of participants’ distress or discomfort during telephone interviews, on two occasions interviews were suspended for a short period. Both times the participants asked to recommence their interview, and one participant commented that he often became emotional when recounting his story. These participants were offered referrals to the mental health organisation Beyondblue and to GAMMA NSW, which were declined. It is also notable that references to suicidal ideation and suicide attempts were made by six participants during interviews. The research topic evokes strong memories and deep emotions and future studies of mixed orientation marriage should prepare researchers for the possibility that participants might report suicide attempts. Interviewers should be prepared by having contact numbers for mental health support organisations to refer participants. A debriefing mechanism for researchers is also recommended before commencing future studies on this topic.

Centre for Social Research in Health 6 ‘Comfortable in my own skin’: Stigma, mental health and wellbeing among married men who have sex with men Outline of main themes

The data set comprised a thick description of events and issues that affected the lives of MMSM. Several main themes regarding stigma and mental health were identified and are discussed below. This analysis of participants’ narratives describes a life-long journey; it begins by situating the men’s lives within a particular socio-historical and cultural setting where emotional and sexual development during early childhood, adolescence and young adulthood were prescribed by the tenets of heteronormativity. The cultural repression of homosexuality and bisexuality and the invisibility of gender and sexual diversity within men’s social, religious and family backgrounds had profoundly impacted participants’ lives, and encouraged the decision to marry, which laid the foundation for the development of poor mental health, maladaptive coping strategies, and a late-in-life coming-out. The decision to come-out as gay or bisexual simultaneously revealed and resolved, compartmentalised behaviours and mental health issues. Participants’ wellbeing, and in certain instances the wellbeing of their wives and families, improved as an outcome of disclosure and separation, or the renegotiation of marriage to allow both partners greater freedom.

1. Compulsory heterosexuality: ‘Jack, you can’t be a hairdresser’ Het[erosexual] culture thinks of itself as the elemental form of human association, as the very model of inter-gender relations, as the indivisible basis of all community, and as the means of reproduction without which society wouldn’t exist. Heteronormativity creates a language that is “straight.” Living within heteronormative culture means learning to “see” straight, to “read” straight, to “think” straight. Michael Warner (1993), Introduction [p. xxi] Heteronormativity is a term widely used in contemporary critical theory to describe the social, legal, cultural, organisational and interpersonal practices that support taken-for- granted presumptions about gender and sexuality, such as the naturalness of sexual attraction between men and women (Kitzinger, 2005). In this world view, heterosexuality is seen as natural, normal, unproblematic, and desirable. Arguably however, heterosexuality is not normal; it is just common. And the weight of numbers is reflected in an overarching theme concerning the stigmatisation of homosexuality and bisexuality, and the disciplining effects of heteronormativity on gender and sexual identity formation during childhood, adolescence and early adulthood, in particular the demand for compulsory heterosexuality. This theme speaks to how, as children and young adults, the men in this study learnt from an early age to ‘see’ straight, to ‘read’ straight and to ‘think’ straight:

Centre for Social Research in Health 7 ‘Comfortable in my own skin’: Stigma, mental health and wellbeing among married men who have sex with men Outline of main themes

[My mother] sat my sister and myself down and I would have been 13 at the time, she sat us down and told us that she could forgive us for being all sorts of things but she would never forgive us if we were homosexual, which in hindsight was a defining moment … Gavin, 54 The effect of compulsory heterosexuality on the development and shaping of individuals’ sexual identity and sexual practice was by far the most salient theme. Indeed, heteronormativity was so powerfully present in these data that it inhibited participants from self-acknowledging, much less disclosing to others, their same-sex attraction, sometimes well into mid-life. Instead, to avoid stigmatisation and to ‘fit in’ with the dominant social- relational landscape, men tried to emulate heterosexuality by marrying: … [I] grew up knowing what family was and understanding that you know that’s what you do … so you grow up, you find someone to marry, you get married and you have children and that’s life … [that meant] I was of this mind of “I can’t be gay, I don’t want to be gay, I’m not identifying with this …” Peter, 50 Participants were often made aware, explicitly, that no deviation from heterosexuality would be tolerated, with banishment from the family being punishment in some instances. In retrospect, men perceived their life course and their mental health and wellbeing, as rooted in the constraints of compulsory heterosexuality, and the fear of not measuring up to the norms of hetero-masculinity. Beyond family, participants were likewise socialised and indoctrinated into very particular constructions of masculinity and sexuality within institutions that were, explicitly and implicitly, intensely heterosexist and homophobic. Schools, sports clubs and churches, like families, were the structural mediums through which transgenerational homophobia was communicated and enacted. During their formative years, participants had no desirable alternative conceptions of gender, sexuality, masculinity and family available to them: As a 14-year-old, I remember saying to my brother and my father, “I’d like to be a hairdresser”. Their words were, “Jack, you can’t be a hairdresser, you’ll be a poofter if you become a hairdresser” … So immediately, I shut the gate on that … Jack, 58 These widely reported prejudiced attitudes encouraged the repression of any growing sense of difference among participants in order to accommodate the wishes of parents, to live up to friends’ expectations, to meet the demands of teachers, coaches, and employers, and to be accepted as legitimate people within their local communities. This ‘straight-jacket’ delegitimised freedom of expression of gender and sexuality, proscribed future occupations, encouraged heterosexual marriage and erased the notion of sexual fluidity.

2. Poor mental health: ‘That’s why young men kill themselves’ A second overarching theme in these data, and one that intersected with compulsory heterosexuality was poor mental health; participants reported a wide range of psychological and emotional conditions, including internalised stigma, depression, anxiety, suicidal ideation and attempted suicide. While not all participants reported poor mental health, all participants were aware of the stigma associated with being gay or bisexual, and they were aware of the social sanctions against extra-marital relations. Stigma layering (i.e. the stigma of being gay/ bisexual plus the stigma associated with extra-marital sex) increases the likelihood of

Centre for Social Research in Health 8 ‘Comfortable in my own skin’: Stigma, mental health and wellbeing among married men who have sex with men Outline of main themes internalising stigma, and in this study internalised stigma shaped men’s sense of esteem, as well as their attitudes and practices. Self-descriptions of ‘underlying insecurity’, ‘self-hatred’, ‘low self-esteem’, and ‘self-loathing’ indicated how internalised stigma in particular was a barrier to good mental health. Participants also reported panic attacks, irrational thinking, insomnia, episodes of acute paranoia, feelings of isolation, anger at society, self-harm, and mental anguish about abandoning children, with some men experiencing an ‘emotional crash’ and ‘complete meltdown’ during their marriage. They expressed frustration with the lengthy and convoluted processes of self-awareness and self-acceptance and some ruminated obsessively about the implications of their situations, with one man describing the effects as: Waves of massive guilt, for you know, what was I doing to my family? Waves of terror about what it would mean if I was found out … I was working in [a factory]; it was a very masculine work force. What would happen if they found out? Feelings of financial ruin, I’m going to lose my house, I’m going to have nothing after working so hard for so long. I’m going to lose my children. My children might not want to love me anymore. My mother will not want me anymore or she’ll hate me or she’ll think that I’ve you know, that I’m a bad person, all these things. It was very overwhelming at the time. Gordon, 44 There was a palpable sense of guilt about being sexually and emotionally attracted to other men and some participants expressed feelings of heterosexual inadequacy (‘I could not be a full man for my wife’). Underpinning reports of guilt and feelings of inadequacy was confusion about the nature of sexuality; how can a man have a strong desire for children and a normal family, yet be sexually attracted to men? One participant reported ‘the cognitive dissonance, it tears you apart’. These heteronormative views and negative internalised attitudes ‘informed’ participants’ poor understanding of sexuality, which meant that most men took full, personal responsibility for their circumstances, rather than seeing their circumstances as at least partially a product of socialisation into a restricted conceptualisation of human sexuality. Despite some men being highly educated and well-travelled, their narratives often reflected remarkably unsophisticated constructions of homosexuality, which evokes Warner’s (1993) statement about ‘Living within heteronormative culture means learning to “see” straight, to “read” straight, to “think” straight.’ For example, one highly trained professional reported that ‘I didn’t understand the concept of sexual orientation’, because his religion had taught him that homosexuality was ‘just a temptation, you’re not allowed to do that’. Indeed, participants who were Christian reported that having a religious background ‘adds the extra layer of shaming and guilt, because of your moral beliefs and what your parents have taught you and what your Church keeps saying’ (Grant, 65). Confusion and simplistic understandings of sexuality led some men toward depression. For example, Tom 38, did not want to be attracted to men, he wanted to be ‘normal’, he wanted to be ‘a full man’ for his wife, and he wanted all the privileges associated with heterosexual masculinity; children, a home and the respect of his friends and work colleagues. Below, he referred to his experience of sex with men at beats (i.e. public spaces such as parks and toilet blocks) during his 12-year marriage. He saw a relationship between confusion around sexuality, sexual repression and suicide among younger men:

Centre for Social Research in Health 9 ‘Comfortable in my own skin’: Stigma, mental health and wellbeing among married men who have sex with men Outline of main themes

… [T]he amount of married men that I ran into in beats and stuff was ginormous. It’s absolutely incredible how many are doing it and I think for me it’s a big problem. I think the whole sexuality thing is behind a lot of suicides, a lot of depression and it’s unspoken about … [later] I sort of feel like I needed to tell the world … this is what happens to us … They [the mental health experts] need to know that this happens … I think they’d solve so many young men killing themselves, because those answers never come out and I reckon underneath it all, that this is the problem. That’s why young men kill themselves. You know when they sit there and say, “We had no idea why he did it”, this is why. This secret is so easy to keep inside your body yourself, it destroys you inside, but it’s so easy to hide from everybody else. Tom, 38 Suicidal ideation and suicide attempts were reported by six men in the study. Some men felt trapped and ‘unloved’ or so confused and alienated by their circumstances that at times life became overwhelming: I think it’s important that I say this, it’s not necessarily because I particularly want to, but there was one point that I attempted suicide during that period [crying]. Jessie, 45 Participants referred to knowing men who had ended their lives to avoid coming-out to wives and families: ‘[His family] knew he was depressed and anxious and now he’s taken his life and they have absolutely no idea why …’, and they spoke of men leaving their wives instead of coming-out, so that the real reason behind their marriage break-up (i.e. same-sex attraction) was never revealed. Participants’ poor understanding of sexual orientation, the confusion around their sexuality, and their resultant poor mental health is a product of an historical disengagement with the notion of sexual and gender diversity. In men who reported depression, anxiety and suicidal ideation, these conditions were often self-managed and chronic because participants did not know where they could go for help or who they could trust to gain support; there was a lack of awareness regarding the appropriate mental health professionals to consult. Mental health was often left unchecked, which impacted negatively upon family dynamics: There’s no question in my mind that I lived a tortured life for most of my married life. I thought I was in love with my wife, but I found out within a few years, well it was a marriage of convenience, but that depressed me intensely. I reacted strongly and my kids suffered as a result … Grant, 65 Mostly however, men in this study expressed a strong love for their wives, and participants were very concerned about how their behaviour affected their family’s wellbeing, and how they could minimise the harm to loved ones and the damage to reputations: [B]ut there was certainly a lot of the mental stuff was, “well what should I do, should I just disappear, should I disappear at sea or somewhere. I don’t want to put people through grief”. But then I thought I’d go overseas and gradually lose contact with everyone, perhaps join some [professional] group in another country and then just gradually fade out of their lives. Theo, 67 Despite many reports of poor mental health and negative affect among study participants, there were also instances of personal insight and self-acceptance: I think I handle life on the whole fairly well and even for my realisation of my sexuality, I wasn’t stressed about it. Sure, it takes time to sort these things out … I knew that I

Centre for Social Research in Health 10 ‘Comfortable in my own skin’: Stigma, mental health and wellbeing among married men who have sex with men Outline of main themes

could sort of manage if [my wife] didn’t want me to stay, so fortunately for me, I’ve been protected from a stress and a depression … you know, realised myself and I accepted myself, which is often the difficulty. You’ve got to accept the situation yourself and say, “Okay, well this is really who I am” and move on … Wayne, 55 Most men had separated from, or had divorced their wives at the time of interview however three participants remained married after coming-out to family and close friends. One of these men said that he preferred to forgo sexual fulfilment for the emotional support and satisfaction of having a life-long partner to grow old with. This was despite him ‘living in the middle band’ where he never experienced intense emotional highs and lows, ‘like a dry alcoholic’. Nevertheless, his wife and family, who were aware of his attraction to men, were the most important and stabilising elements in his life.

3. Coping in a mixed orientation marriage: ‘It was sort of like going to the movies’

3.1 Compartmentalisation and integration A further overarching theme in these data, which intersected with heteronormativity and poor mental health, was compartmentalisation and integration of same-sex attraction and behaviour. Participants’ practice of compartmentalising (Showers & Zeigler-Hill, 2007) same- sex attraction and behaviour within the context of heterosexual marriage was a key strategy used to facilitate sexual fulfilment and to cope with the demands of a mixed orientation marriage. Compartmentalisation of sexual attraction and sexual behaviour operated at both an individual and social level. At an individual level, compartmentalisation refers to the process where people construct contextualised selves that organise positive and negative beliefs about the self in a way that serves either implicit or explicit self-goals. At an individual level, compartmentalisation allows conflicting ideas about oneself to co-exist (i.e. it is a process to reduce cognitive dissonance) (Festinger, 1957; Frasca et al, 2012). At a social level, heteronormativity compartmentalises sexual identity into the straight-gay (i.e. normal/ abnormal) binary, which is how people have been socialised to think of human sexuality. Not all study participants engaged in compartmentalisation, however there were significant examples of the practice described throughout the study. In this study, compartmentalisation helped to reduce the emotional significance of same-sex attraction in men’s lives, by emphasising a distinction between love and sex (e.g. ‘I love my wife, whereas men are just sex’). By disassociating love and sex, participants attempted to integrate same-sex attraction and behaviour into their married lives. Participants characterised their sexual fantasies and interactions with other men as episodic, casual, anonymous and emotionless, and therefore representing no threat to their marriage. Men split their lives into disconnected segments and controlled assiduously for any overlap, which might reveal their extra-marital activities. Some were more successful at the practice than others, for example men who travelled for work were provided with more opportunity to meet other men and to compartmentalise same-sex behaviour, integrating sex with men into their emotional and professional lives, than were men whose work and family lives were tightly structured (i.e. family contexts where a wife would notice when a husband was 30 minutes late getting home from work). However, the strategy of compartmentalising did not

Centre for Social Research in Health 11 ‘Comfortable in my own skin’: Stigma, mental health and wellbeing among married men who have sex with men Outline of main themes always reduce internal conflict, or cognitive dissonance, as theory suggests it should, as indicated by an example of the practice of compartmentalising described below: I would save up cash and I would buy a gay porno … and so I would put that on, on my day off when [my wife] was working and the kids were at school, and have a masturbation session to that. And then I’d feel … so guilty that I would take a hammer to the video and smash it to smithereens. Then I would take it down to the waterfront to a whizz bin … and bury it low down in the whizz bin and I felt so guilty and horrible that I would go a few weeks, before I decided, “Oh this is ridiculous, I need to enjoy this” and I would buy another video, and so be it. Jack, 58 The individual level psychological benefits of compartmentalising may have been limited by the effects of social-level factors. Participants noted the widespread belief among their friends, families, work colleagues and wives - society in general - that for the most part sexual identity consists of impermeable, bounded categories or compartments, that is, people are either straight or gay (e.g. the adage: ‘He’s married with children, so he can’t be gay’). Such beliefs about sexual identity underpinned the need for and development of partitioned sexual behaviour among MMSM: … I think I was able to compartmentalise [sex with men] and just, “Yeah, that was an event and yeah, that was fun and I liked that”. It was sort of like going to the movies. Peter, 50 Compartmentalising sexual practice however was both adaptive and destructive; it enabled men to explore their sexuality, for example, by watching gay porn or cruising for casual sex. Yet the stress evoked by attempts to integrate (Showers & Zeigler-Hill, 2007) men’s self-concepts (I’m a married man/ I want sex with men) was significant, and the stress of managing disparate sexual identities and practices in the context of heterosexual marriage exacerbated feelings of anxiety and depression. Internalised stigma was a barrier to participants building an integrative self-structure (i.e. having a healthy balance between one’s positive and negative self-concepts), which led them to experience strong negative emotional states and low self-esteem.

3.2 Managing stress Participants used a range of coping strategies to manage the stress of a mixed-orientation marriage, including drugs and alcohol, support via friendship networks, professional one- on-one counselling, group counselling, psychological defence mechanisms, work, travel, creative pursuits and formal support groups. Some self-medicated with alcohol however there was no reported use of illicit drugs. Doctors, psychologists and counsellors were consulted to assist with coping, and several participants were prescribed anti-depressants and anti-anxiety medications. Generally, however, participants said that there is a limited pool of mental health professionals that are trained to assist MMSM from which to choose. This was also alluded to by a participant with many years of experience of counselling MMSM: So I’m very careful to suggest … when the guys are saying “We need to go and see a marriage counsellor” or whatever, I go “well, don’t just pick anyone. Pick one that actually understands the perspective here, which is about sexuality and not so much about marriage, because it’s not the marriage that you are going to go and talk about.

Centre for Social Research in Health 12 ‘Comfortable in my own skin’: Stigma, mental health and wellbeing among married men who have sex with men Outline of main themes

It’s the sexuality and the issues that causes about your marriage” and they’re like “Oh”. So … what I’ve heard from guys is they’ll go to a marriage counsellor and if they are not familiar with mixed orientation or sexuality, then it tends to be very biased towards the woman … so I’ll go, “Right so maybe you need to find another counsellor who’s actually a little bit more open minded about the situation that can help guide you both to making better decisions, because this counsellor isn’t going to solve the problem for you”. Peter, 50 For the most part, participants from religious backgrounds did not view their religious congregation as sources of support and they were careful to avoid disclosing to their church leaders. One participant had consulted a Christian psychologist and received a referral for ‘change therapy’ but he withdrew from therapy after a period due to worsening depression. Despite this experience, he commented on the positive support he had received from his fellow parishioners since coming-out. One of the more common coping strategies reported by participants, particularly as younger men, was the classic defence mechanism of denial (Cramer, 1987). Denial of same-sex attraction (i.e. to oneself and to others), and reframing sexuality to minimise acknowledgement of same-sex attraction, was often behind participants’ delayed coming- out, and facilitated performances of heterosexuality, which helped to sustain family life. Denial appeared to provide time and a space for participants to (both consciously and unconsciously) process the implications of being gay or bisexual: I was in such denial of it, that if anyone had asked me “are you gay?” even when I knew what the word “gay” implied and even after I’d had sex with men for decades by this time, I would still have said, “No, I’m not gay. I’m heterosexual, but I enjoy sex with men on the side”. That was my standard justification to myself, probably up until I was 40 at least. “I’m not gay, no I’m not gay”. Grant, 65 … I knew in my head that [I was always attracted to men], but I guess I was just hoping it would go away, just fade away and go away and then not exist anymore … the denial part of it was that was not going to happen … I denied agreeing with my mind that, “this is not going to change Tom, this will be with you for the rest of your life.” I think that’s where I denied it, I just kept saying, “no it will just fade away and just won’t ever think about it ever again” but it doesn’t happen. Tom, 38 Coping was also facilitated by any activity that would distract participants from self- exploration, self-criticism and over-rumination. Distractions such as business travel and hobbies provided respite from tensions at home, and from the pressures of work, and afforded the time for participants to think through their situations and to make plans for life after coming-out. The NSW chapter of the international support organisation for men in mixed orientation marriages, GAMMA NSW, was a focal point for obtaining information, counselling and support among participants, some of whom travelled far to attend sessions. Among participants who had attended GAMMA NSW the service was very highly regarded. Coping was enhanced by engagement with the expertise of counsellors from GAMMA NSW and through meeting and mixing with other men who were, or had been, married. Currently however there are too few services for MMSM and the issue of mixed-orientation marriage, according to participants with many years of experience of seeking mental health support,

Centre for Social Research in Health 13 ‘Comfortable in my own skin’: Stigma, mental health and wellbeing among married men who have sex with men Outline of main themes remains poorly understood among mainstream (i.e. not LGBTIQ-related) psychologists and counsellors. A scaling-up of support services for all members of affected families could improve access to appropriate modes of support, as a participant explained: I think there’s still a real problem with the lack of formality or support networks for previously married mums and dads and for their kids, because kids who grow up in same-sex families don’t see that as an issue, whereas kids who have grown up previously in heterosexual families, the biggest struggle for a lot of the dads is having raised kids or being in a same-sex attracted or a heterosexual environment where religion or social norms and all these sorts of things have condemned homosexuality, it’s much, much harder to come out. And coming out not only affects the dad, but the wife and the kids … James, 40-something

4. Coming-out gay/bisexual: ‘It was not something she could make herself prettier’ These data demonstrated that mental health and wellbeing were significantly improved by coming-out as either gay or bisexual, despite this being an acutely stressful event in the lives of most participants, and in the lives of their wives and families. The process of self-acceptance was often arduous and circuitous, involving an ongoing internal-dance of approach-and-avoidance of the topic, usually over the course of many years. For most participants, the decision to come-out was mediated by fear and anxiety about the implications and consequences of openly identifying as gay or bisexual, particularly in relation to how it would affect their wives: I had reached the conclusion in my mind that I was homosexual. I wasn’t bisexual … and I needed to be honest with my wife, so I told her first how I felt and she obviously went through a range of emotions over those weeks that followed … so you can imagine how devastated she was. We spent sort of six months trying to understand what it meant, whether we could just continue on, whether we should separate, whether she’d allow me to see someone or you know, what our future would be, if anything. Gordon, 44 There were a variety of reported outcomes from coming-out. While participants were relieved of an onerous psychological burden of secrecy, their wives, most of who were completely unsuspecting, bore a heavy emotional burden, and the process of separation was often long, deeply emotional and fraught with a range of difficulties, as Gordon goes on to explain: Probably the first minute [after I came-out to my wife] was, you know, denial. Within the first couple of days it was devastation, sadness, overwhelming grief, like she’d lost me. You know she couldn’t compete with this. It was not something that she could make herself prettier … so I could see that she was really suffering. But then her emotions turned to rage, very strong anger, wanting to get revenge and harm me, not physically, but financially. Actually … [a family member] was giving her advice on how to ruin me financially, how to leave me with a heap of debt. But anyway, she didn’t do any of those things. Gordon, 44 At times, wives reportedly responded with empathy following their husbands’ coming-

Centre for Social Research in Health 14 ‘Comfortable in my own skin’: Stigma, mental health and wellbeing among married men who have sex with men Outline of main themes out. Among participants who remained married after coming-out, their relationships were renegotiated to suit a new context: one woman had accepted her husbands’ attraction to men but did not want to share him with a man; another wife of a participant agreed that her husband could have a male lover as long as they stayed married, and a third couple had stayed together for several years after the husband had come-out so that their children had a stable environment while completing school; they then separated amicably and the family remain in close contact. … I was quite surprised I must say when I did tell [my wife that I was gay] and all I got was support and I thought that was fantastic. Andy, 57 I only opened up myself when I was 50, just after my 50th birthday to my wife and she understands and ever since then, it’s been a great big learning curve and I’ve really come out. My kids know. Not everyone in my family knows, but a lot know and I feel a lot better, but through my years I had suffered a lot of depression and anxiety and stuff and I tried to hide a lot of it. Clive, 53 For some, ‘coming-out’ was partial and provisional; it meant being open about the husbands’ sexuality only within the family, or among family and close friends. For the most part, a partial coming-out was employed to protect the reputation of families, and to ward off outsiders’ criticism of wives for staying in the marriage, particularly for those who were from conservative backgrounds. Participants wanted to maintain control over disclosure for a range of reasons, but often it was to protect adolescent children from the risk of homophobic bullying: It’s important to know too, when I say “I’ve come out”, I’m not completely out about my bisexuality, my wife knows, my two children know and there are some family members like my parents, my wife’s parents and few other people that know, but generally speaking to the outside world, I am still a married heterosexual man … part of it is to deal with the culture of [my workplace], a lot of it is to do with respecting the wishes of my wife and one of my two children … my wife doesn’t want me to come out with some of our friends and family, because she fears the judgment that she will get for staying with me. One of my two children would be quite comfortable with me being open and honest to the general population, the other son has also expressed his desire for me not to be open to everybody. Again, I think that is because of the fear of how his friends or girlfriend might perceive that and what they might make of it. Jessie, 45 Coming-out meant that the compartments participants had constructed to separate their private persona from their public married life could be dismantled, and an integrated self could begin to emerge. Coming-out was an epiphany and a major milestone in participants’ lives, despite sometimes taking decades, because it enabled the development of an authentic identity and sexual citizenship: The best thing that ever happened to me after I came-out was … to integrate my whole being into one for the first time in my life, and that was the best thing that ever happened to me. Grant, 65 However, coming-out also represented a shift in power where men became aware of losing social status, in part by being stigmatised by disapproving wives, family, friends, workmates and employers who repositioned participants as the abject homosexual ‘other’:

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… I’m you know, white Anglo Saxon, private school, privileged background and for me … a lot of the privilege that I had in the straight world was completely invisible to me until I came-out, and then having come-out and dealing with the quite subtle discrimination that’s there … I have to keep having compassion for people, because I know that I couldn’t see [the discrimination], so why should they? Gavin, 54 This is consistent with the tenets of stigmatisation as being a social process that produces, perpetuates and legitimises social inequality (Parker & Aggleton, 2003). Participants on one hand reported experiencing great relief from coming-out yet on the other hand, it exposed them to public stigma, which has its own unique social and mental health impact. Nevertheless, compared to the reported negative effects of internalised stigma, participants who had come-out as gay and bisexual said that they experienced an overall improvement in their sense of wellbeing, or as one man explained: I’ve grown comfortable in my own skin. Bill, 60

5. Current wellbeing: ‘I feel humbled by the journey that I’ve had’ All accounts of mixed-orientation marriage in this study were retrospective with some accounts of poor mental health, coming-out and marriage breakdown and separation occurring over 20 years prior to the study. Several accounts were quite recent (within the past five years), and one participant was interviewed within a week of his marriage ending in 2015. Consequently, reports of current wellbeing varied widely; from the excitement of self- discovery and fulfilment to ongoing issues with self-esteem, sexual identity and fears about the future. Many participants had had the benefit of time to heal past relationships and to gain an insight to their earlier life decisions regarding marriage, their compartmentalised behaviours, and their coming-out. Of three men who remained married at the time of interview, two of these men had male partners after having negotiated arrangements with their wives and families. Wellbeing improved in men whose same-sex attraction and behaviour became openly integrated within family life: Being married, my wife’s allowing me to have a male partner and we’re happy with that and she’s happy. He’s been to visit us. The kids and I are going camping with him in November and stuff. My kids are happy with it and stuff like that, so. Clive, 53 [I am] living in a beautiful part of the world, got a fantastic, strong, long lasting relationship with my wife, but still able to have some intimate relationships with guys, able to fulfil myself sexually on both sides of the fence, yeah, I’m living the perfect life [laughs]. Jessie, 45 Conversely, when separation and divorce were recent events or were currently in train, wellbeing was often determined by the relative perceived benefits and losses of the changes participants were experiencing. There was a sense of relief from no longer having to lead a double-life however some men were apprehensive about their future lives as ‘out’ gay and bisexual men: You know right at the moment, at this moment, I don’t know how it’s going to be at all. I don’t know where I’ll be or what I’ll be or who I’ll be with or anything. I feel like for me you know, I’ve just gone through one of the biggest things in my life and I guess I’m

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going to be a different person in five years’ time. You know, but what kind of person I’m going to be, I don’t know. With the gay side of things I guess you know I’m not going to deny that, if I meet a man I meet a man, if I meet a girl I meet a girl. I kind of feel that it’s probably going to be a man, because I don’t want to have to be with a woman again and then go through all that again, do you know what I mean? I’m probably better off just being a single person, being my own person and … not restricting myself. Tom, 38 Following the process of separation and divorce, participants generally felt better about their current life and about their long-term future. For example, after years of worrying about the implications of being gay and married, to the point of suicidal ideation, at the time of interview some men were grateful to have experienced a mixed-orientation marriage for the opportunity it provided for personal growth: Look, I’ve never felt stronger. I’ve never felt stronger. I feel empowered by the support I have from family and friends. I feel energised by the environment that I work in. I feel humbled by the journey that I’ve had and I feel immensely proud in the way in which I’ve created a highly successful career … I feel proud that I’ve been able to take my family and my friends on this journey to understand what being a gay male really is and it’s not what we thought it was. It’s not what I thought it was and it doesn’t need to change you as a person. I’ve not changed as a person … So my emotions at the moment are all very positive feelings. Gordon, 44 As expected, wellbeing was enhanced by the resolution of conflict within the marriage, by reaching a mutually agreed decision to separate or divorce, through negotiating an equitable distribution of family resources, and by establishing ongoing positive and mutually satisfying contact between family members. Not all marriages ended in this way, but for those couples whose marriages had ended amicably, or whose marriage had ended without incurring irreparable damage, the distress of separation and divorce was not permanent: So I’ve got a nice lovely family … I get on really well with my kids. I don’t discuss much of it at all, because they don’t need to know. I keep my life separate to theirs in the sexual side of things and I’m still very good mates with my wife. In fact … only recently … she had said to somebody, “Jack will always be my best friend, because we were always friends. We were friends before we were lovers” and we’ve remained quite that way. So there’s many things I can’t discuss with her and don’t, but I’ll always be there for her. Jack, 58 Reports of current wellbeing were affected by the influence of heteronormative values, by the state of participants’ mental health, by the problem- and emotion-focused coping strategies that were employed to manage distress, and by the experience of coming-out and finding a partner. The resolution of these factors largely determined the degree to which participants reported being ‘comfortable’ in their own skin: Interviewer: I was just wondering how you are travelling today? Participant: Fabulous, absolutely fabulous. And I mean that in every sense of the word. Things got very much better the day I came out and they continue to get better and better ever since … [later] I have the most wonderful person to share my life with. I really think after I met [my husband], I really then discovered for the first time what love really is … I mean, I’d watched romantic movies and read romantic books like all of us do when I was younger and never could quite get it, why were these people so

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ecstatic? It’s only since meeting [my husband] that all those romantic comedies and what not suddenly made sense. I think the difference is the whole mental attitude that changes when you are no longer living under a cloud and living your authentic self and that’s what I tell other people now: “You’ve got to be who you are. You can’t suppress a whole part of your whole nature and personality and you can’t live behind a wall or a façade that is just damaging to yourself”. That has been perhaps the biggest revelation to me. Grant, 65

Centre for Social Research in Health 18 ‘Comfortable in my own skin’: Stigma, mental health and wellbeing among married men who have sex with men Conclusion

This study found that the stigma of homosexuality and bisexuality is alive and virulent. Among same-sex attracted men who had cultivated a heterosexual identity, sometimes well into their 50s and 60s, denying their sexuality (or misunderstanding their sexuality) for so many years had serious mental health consequences. As young people, participants had learned to deny and repress their same-sex attraction to conform to the tenets of heteronormativity, which permeated their communities, their families, and their social networks. Participants said that as young people they strove to fit in, and aspired to have their own lives reflect the common relationship patterns they saw around them, that is heterosexual marriage, children and family life. This was despite some men being aware of their same-sex attraction from an early age. Integrating same-sex desire with the demands of heteronormativity within often conservative, rural or regional, and religious social contexts was unsustainable over the life- span for study participants. Compartmentalising assisted men to explore their sexuality while married yet, compartmentalising also exacerbated anxiety, and produced and perpetuated a variety of psychological problems such as depression. The study findings suggest that interventions to improve mental health among men in mixed-orientation marriages should view compartmentalisation and denial as short-term coping strategies. Over the longer term, MMSM should be encouraged to seek appropriate professional support. However, some men in this study reported difficulty in accessing a mental health professional when they needed one with experience of working with gay and bisexual men, and even fewer mental health professionals were said to have experience of mixed- orientation marriages. Few mental health professionals were equipped to assist men to come-out, despite this being a turning point in the men’s psychological health and wellbeing. A lack of mental health expertise around issues affecting gay and bisexual men indicates a need for innovative interventions such as online resources targeted at affected individuals, and workforce development programmes to familiarise and upskill mental health professionals about sexuality-based issues, including mixed-orientation marriages. Coming- out also precipitated a very difficult course of family breakdown and social dislocation. Further research is needed to better understand the experience of wives and children in mixed-orientation marriages and to develop appropriate interventions for the families of MMSM. Addressing mixed orientation marriage requires broad social- and cultural-level change, first by challenging and disrupting the taken-for-granted assumptions that underpin heteronormativity. The findings of this study suggest that interventions to improve mental health must be informed by the exigencies of heteronormativity, which reinforce the widely accepted binary construction of sexuality (i.e., all people are either homosexual or heterosexual). To move beyond compulsory heterosexuality, sophisticated cultures and

Centre for Social Research in Health 19 ‘Comfortable in my own skin’: Stigma, mental health and wellbeing among married men who have sex with men Conclusion societies by definition must come to terms with gender and sexual diversity. However, given the rise of a conservative populism across Western politics in recent years, programmes of gender and sexual diversity in education and health are increasingly positioned as ‘politically correct’, of relevance only to minorities and therefore a low priority for government funding and support. Indeed, education programmes promoting gender and sexual diversity aimed at youth have become targets of derision, representing a clear challenge to future health promotion efforts for people from LGBTIQ populations, including MMSM. While this study did not recruit men from culturally and linguistically diverse populations it is likely that these communities are exposed to equally prescriptive beliefs about gender and sexuality. Interventions among all population groups need to challenge the naturalness of heterosexuality and heteronormativity, to promote gender and sexual diversity. Interventions that disrupt the hegemonic construction of gender, sexuality and masculinity are likely to require political will and extended time-frames for their effects to be measurable. Expanding people’s understandings of the things they have known all their lives and held dear, such as masculinity and heterosexual marriage, is achievable, but is a major undertaking for health promotion education. Diverse approaches will be required to target affected populations because as this study shows, MMSM come from all walks of life, including religious communities. Indeed, the intersection of faith, sexuality and mixed-orientation marriage is creatively represented in a high quality 30-minute documentary available from You-Tube, titled ‘Here I Am’ about MMSM for people from Christian backgrounds. The writer and producer intended to use the documentary to advocate for LGBTIQ people from religious backgrounds by improving awareness and knowledge among Christians of human sexuality and same-sex relationships. Similarly, innovative resources are needed to sensitise people to the existence of mixed-orientation marriages and to provide information without reinforcing negative stereotypes about gay and bisexual men. Innovative resources for MMSM may be discreetly and sensitively targeted at traditional publications for men, such as print and online sporting magazines, to reach the affected population. Developing resources that will open a conversation may be the first step to neutralising the worse effects of stigma related to sexuality and to improving the mental health and wellbeing of men, women and children in mixed-orientation marriages.

Centre for Social Research in Health 20 ‘Comfortable in my own skin’: Stigma, mental health and wellbeing among married men who have sex with men References

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