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