Managing the Triple Threat: Strategies for Older Gay Men With HIV

Managing the Triple Threat: Strategies for Older Gay Men With HIV

When have you felt like the only one? The only artist, the only person of color, the only Democrat? I recently asked this of a class of graduate social work students at NYU, Their eyes were closed as I took them through this exercise, asking them to recall as much as they could about the experience emotionally and physically.

Where were you? What was happening? Who were you with? How did it feel to be the only one? What was going on in your body -- your stomach, back, shoulders?

Then I asked them to take a mental photo of the expression on their face, to save the picture, and to slowly come back to the room. What followed was a discussion of the effects of stigma on our physical health, the way we interact with others, and our feelings about ourselves.

"I felt alone and scared," one student stated. Another was close to tears: "I felt insecure and thought I was going to throw up." Another jumped in, "Not me. I was angry."

"What if a social worker approached you at that moment?" I asked. She replied quickly, "I would have bitten her head off. I didn't want to talk to anyone."

For social work students, the exercise is especially important because they must be able to empathize with their clients, to understand not only the way stigma can spoil one's positive identity but also how stigma and the acceptance of being stigmatized can serve as obstacles to the very help these students want to provide. Only when they remember what it's like to feel like "the only one" can they bridge the gap of mistrust and begin to build the alliance that can help heal the wounds of social stigma.

I learned this exercise when I was a social work intern at SAGE doing sensitivity training on LGBT aging with Arlene Kochman in 1992. And, despite the gains the community has made over the past 23 years confronting homophobia, the lesson is still relevant.

The Triple Threat

Mark, 54, feels sideswiped by the ageism he experiences from other gay men. He feels invisible in the gay community, where he once received support: "It's all about young, pretty boys, blah blah blah, whatever."

Gay men often refer to aging with HIV as a "triple threat": the homophobia they've always encountered, the stigma of HIV, and now ageism as they live into middle age and beyond.

Homophobia is a continuing reality in the lives of gay men. Over 75% of LGBT adults aged 60 to 91 have experienced some form of victimization due to their sexual orientation (D'Augelli & Grossman, 2001). An HIV diagnosis can reopen the old wounds of homophobia, and older adults continue to experience the consequences of HIV stigma in their daily lives. Additionally, for many HIV-positive gay men, who never thought they would live to middle age, growing older involves confronting the unanticipated realities of ageism. Here's what three gay men over 50 say about the triple stigmas they've experienced (names have been changed for privacy):

Luis, 51: You couldn't walk the streets together. They would beat you up.

Mario, 53: The trauma of feeling like I was the only gay person in the world.... It was always a waiting game of finding out that people really didn't want you around because you were gay. When I was diagnosed with HIV, it happened again -- I literally walked around shell-shocked for about two or three weeks after that.

Mark, 54, feels sideswiped by the ageism he experiences from other gay men. He feels invisible in the gay community, where he once received support: It's all about young, pretty boys, blah blah blah, whatever.

Stigma takes a toll on our mental and physical health. It can lead to depression, a lack of social support, and can affect whether people seek medical and mental health care (Emlet, 2013). These conditions can manifest in physical symptoms and create a negative feedback loop of illness and isolation. Joe, 63, knows the pain of living with stigma: "My muscles turn to stone", he says, from the depression of living an isolated life. Managing the triple threat of homophobia, HIV stigma, and ageism is essential to gay men's health and well-being.

Fight or Flight

Humans have an innate physical reaction to danger. Our bodies flood with hormones that propel us into action. We are compelled to act quickly, either to confront an aggressor or to flee to safety. This instinct, referred to as the fight/flight response, can also kick in when we react to stigma. We respond to the threat of a homophobic assault just as we would respond to an attack from a predator in the wild. Gay men who have been victims of repeated homophobic abuse can experience a fight/flight reaction even when the threat of danger is not immediate. Just the anticipation of stigma can be alarming enough to trigger the fight/flight response.

Anger is the emotional response that compels us to fight. Just as a flood of anger propels us to fend off an attacker, so too can rage surge in our bodies when we experience the assault of stigma. But anger is not a dangerous emotion in itself. Where would the LGBT community be today if an angry mob hadn't fought back against a police raid at the Stonewall Inn in 1969? In fact, activism is a form of channeled anger.

When Joe developed facial wasting, he started isolating. As his family reunion approached, he was torn. He wanted to see family members, but the fear that his HIV diagnosis would be revealed by his face made him hesitate. He weighed the risks of disclosure with the advantages of reconnecting with family members.

Tim, 50, can still get worked up when he hears about someone being discriminated against for being gay or reads about federal cuts to AIDS funding. But he's not getting into fights with the police anymore -- instead, he focuses his anger into writing letters, joining protests, and speaking out as an openly gay man with HIV. When we are aware of our anger, we can find productive outlets for that feeling, like Tim does. Unfortunately, when we are unaware of our anger we can turn it against ourselves and the people close to us in destructive ways.

Fear is the emotional response that compels us to take flight. Just as we might run from an attacker, we can flee from situations that trigger the fear of stigma. Many middle-aged and older gay men remember when the threat of imprisonment, unemployment, homelessness, and violence compelled them to hide their sexuality.

Joe lived through the pre-Stonewall years and learned to be a "private guy" who kept his sexuality to himself and his closest friends. When he developed facial wasting caused by HIV (which he referred to as "the look of AIDS"), he started isolating. As his family reunion approached, he was torn. He wanted to see family members he hadn't seen in years, but the fear that his HIV diagnosis would be revealed by his face made him hesitate. He weighed the risks of disclosure with the advantages of reconnecting with family members and decided to attend. Since then, Joe has joined a support group for middle-aged and older gay men with HIV, to help him rethink his tendency to withdraw. In fact, coming out is not a singular event but a lifelong decision-making process that involves managing the fear of stigmatization. When we are aware of our fears, we can make active and ongoing choices about whom to come out to, when it is safe to self-identify, and how much we want to share about our identity.

Shame vs. Pride

Stigma not only affects self-esteem and identity, but internalized stigma can create a pattern of shame that leads to isolation, depression, and poor self-care. Many of us were bombarded with images of "normal" heterosexuality at a young age. We received messages, often unspoken, that homosexuality was "deviant", "sick", or "shameful". These falsehoods got into our psyches before our sexual identities were fully formed. Because of the unconscious ways stigma is learned, shame can be triggered without our awareness and can manifest in many ways, including:

  • our attitude about ourselves and our self-esteem
  • our ability to socialize
  • our feelings about our "love-ability" in intimate relationships
  • our willingness to advocate for ourselves
  • our belief that we deserve to be treated fairly
  • our sense of hope, safety, and justice in the world

At 51, Peter can look back on his life and see the damage stigma has caused. He realizes that his low self-esteem has held him back from getting the most out of his career and personal relationships. But he is committed to changing his attitudes and behaviors.

I've learned that I must fight off those internalizations. I must keep who I am here, free from those internalizations somehow. Because that's who I really am. And that's a challenge for me.

Mario knows that learning to deal with the homophobia of his youth has made him stronger today. As he puts it, "If you go through that without throwing yourself in front of a bus ..." then you can handle anything.

For many of us, the gay community provided a refuge from homophobia, and positive interactions with other admirable gay people reversed our negative self-view. The gay pride movement told us that homosexuality was not something to be ashamed of, but an aspect of our identities of which we should be proud.

Ronald, 58, found that getting reconnected to the gay community helped empower him as he faced the stigma of aging with HIV:

Being around gay men who are successful gay men, who are out and have been for years, it has somewhat blunted my fear of being discovered.

Research suggests that successful management of homophobia serves a protective function that can help us face the challenges of aging (Kimmel, 1977). Coming out gives us a sense of crisis competence and provides us with tools we can use to combat the challenges of aging. Mario knows that learning to deal with the homophobia of his youth has made him stronger today. As he puts it, "If you go through that without throwing yourself in front of a bus ..." then you can handle anything.

Enhancing Resilience

How can we combat the negative realities of stigma while enhancing the positive strategies we developed to cope with it? We must foster the qualities that enhance our resilience. Resilience can be thought of as "strength plus flexibility". It allows a person to adjust to life's challenges by using coping strategies adaptively, rather than rigidly. When we are resilient, we integrate our past experience with the strengths and support of others to develop new approaches to our problems. Here are four practices you can start right now to help you to build your resilience as you face the triple threat of homophobia, HIV stigma, and ageism.

Affirm Yourself

Many gay men say that a lifetime of stigma has left them with an "old tape" playing negative messages inside their minds. The recording, which can turn on at any time, might tell them they're "too effeminate", "not handsome enough", or "too dull". The tape is different for each person, but the overall message is the internalized expression of stigma: "Something is wrong with you."

The first action you can take to develop resilience is to stop the tape. When you are aware of the "stinking thinking" that stigma generates, redirect your thoughts. Come up with a phrase you can use whenever you catch yourself falling into negative self-talk (like "There's that tape again, sweetie.") or make up a word that stops the tape (such as "zip"). When you use that word you know it's time to change your mind and to distract yourself with new thoughts or activities.

Develop your ability to clear your mind. Paying attention to the present moment is one way to distract yourself from negative thoughts and create a sense of calm. There are several kinds of meditation practices you can use for this purpose. One strategy is simply to pay attention to your breath. Focus on the air as it passes through your nostrils. Feel yourself relax as you breathe cool air in and warm air out. Try that for two minutes when you are feeling stressed.

Change your thinking patterns by reciting affirmations. By focusing on your strengths and positive attributes, you combat internalized stigma. Some positive affirmations include: "I am a good person." "People care about me." "I am worthy of love." Come up with some affirmations that counteract the negative tape of stigma. Practice them in front of a mirror and say them to yourself throughout the day, or when you are experiencing stigmatizing thoughts.

Get Support

The presence of a strong support network can help you manage the challenges of living with HIV and of aging in general. Peers who understand your experience are vitally important when you are dealing with stigma. Even the sense that someone cares is often enough to counteract the negative impacts of stigma on your emotional and physical health.

The gay community once provided a safe haven from homophobia. Gay friends and colleagues offered opportunities for building pride and empowerment. But many older gay men have lost most or all of their social networks to AIDS. How do you rebuild your supports at this stage of your life? Here are ten suggestions for widening your social network:

  1. Renew old acquaintances.
  2. Seek out people with whom you have things in common.
  3. Strike up a conversation with someone you've never met.
  4. Make friends with someone different from yourself.
  5. Don't wait for people to contact you.
  6. Consider professional support through an agency, support group, or therapist.
  7. Adopt a pet.
  8. Pursue a romantic relationship.
  9. Use the internet to cast a wider net.
  10. Form a reading group or some other type of social activity.

Be of Service

"Mature man needs to be needed" (Erikson, 1963). Helping others through productivity, creativity, and passing on knowledge is the primary way you can fight off stagnation in midlife. By demonstrating your value to others you challenge stigmatizing ideas by reaffirming your self-worth. Stigma tells us that we are no good -- that we have nothing to offer and no one wants to hear from us. That is not true. Age and experience have left you with hard-earned wisdom. Through mentoring, coaching, leading, or consulting, you remind yourself of the skills you have to offer.

Consider how you can get involved in your community. What ski l ls do you have to of fer a younger person through teaching or tutoring? Can you help someone who is in need? Have you ever thought about being an HIV peer educator, or participating on an advisory board or advocacy group? What is one step you can take today toward getting more involved?

Have Some Fun

Stigma takes a toll on your mental and physical health. The fatigue and pain of stigma can wear you down without your awareness, leading to isolation and depression. So you need to recharge and replenish yourself with some positive energy. Do you have enough play time in your life? It may seem out of place to end an article on HIV and aging by discussing play. But the ability to play is probably one of the most influential factors in development across the lifespan. When we play we can:

  • Learn new skills.
  • Make friends and socialize.
  • Immerse ourselves in creativity.
  • Channel our energy toward a productive goal.
  • Get our heart rate up.
  • Work out anger.
  • Manage losses in a less charged atmosphere.

Your options for play are as boundless as your imagination. Learn a sport. Take a dance class. Pick up a paint brush. Play a board game. Write a story. Care for animals. Garden. I love giving a toy to kids only to watch them invent a game involving the box it came in.

Conclusion

Optimal aging with HIV involves managing the triple threat of homophobia, HIV stigma, and ageism. When you take care of yourself you counteract the negative messages of stigma. Let's keep a conversation going about HIV and aging that fosters resilience and empowerment in ourselves and our communities.

James Masten, the author of Aging With HIV: A Gay Man's Guide_, is the director of Action for HIV and Aging (ahaproject.org) and a psychotherapist in New York City._