Factors Related to Positive Mental Health in a Stigmatized Minority

Abstract

Objectives:This study investigates factors related to the positive mental health of older Australian gay men, who are challenged by both age- and sexuality-related stigma. Methods: A national online survey was conducted among 422 gay-identified men aged 40 years and older. Positive mental health was measured using the Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS). Results: Regression analyses revealed men were psychologically healthier if they were employed full-time, had a higher income, were in a relationship, received greater social support, had many close friends, felt connected to the gay community, believed the public felt positively toward their group, and had not experienced discrimination in the past year. A multivariate linear regression found social support to be the most important of all these factors, with support from friends particularly critical. Discussion: These findings provide new guidance to health agencies that seek to improve the mental health and well-being of older gay men.

Keywords

positive mental health well-being gay men aging stigma

Like other stigmatized populations, gay men have substantially higher rates of mental illness than the general population (Chakraborty, McManus, Brugha, Bebbington, & King, 2011; Cochran, Sullivan, & Mays, 2003). A recent meta-analysis of 25 studies across seven countries found rates of depression and anxiety among gay men to be 1.5 times greater on average than among heterosexual men (King et al., 2008). In Australia, 41% of nonheterosexual adults meet the diagnostic criteria for a mental illness in a given year, with a large majority experiencing depression and anxiety (Australian Bureau of Statistics, 2007). Similarly high rates have been found in other developed countries, such as the United States (Cochran et al., 2003) and the United Kingdom (Chakraborty et al., 2011).

Over the past decade, a range of factors have been identified to account for the disproportionate burden of mental health problems among gay men, many of which are related to the challenges of belonging to a stigmatized minority, such as facing discrimination, living in fear of discrimination, or experiencing shame as a result of internalized stigma (Burns, Kamen, Lehman, & Beach, 2012; Kelleher, 2009; Kuyper & Fokkema, 2011; Mays & Cochran, 2001). In some developed countries, governments and other public health authorities have reduced at least some forms of institutional discrimination, such as awarding legal rights for same-sex couples. However, equal rights are still lacking in many regions and transforming negative public beliefs and attitudes that give rise to discrimination and prejudice is a challenging task, one that may yet depend on considerable cultural or generational change (Kashima et al., 2010; Klein, Clark, & Lyons, 2010; Lyons, Clark, Kashima, & Kurz, 2008; Lyons & Kashima, 2001, 2003, 2006).

It is therefore important that focus also be given to strengthening the psychological health of gay men, and other stigmatized minorities, so that individuals can better withstand the challenges of belonging to a stigmatized population. For gay men, these challenges can vary considerably with age. Older gay men have spent a large part of their lives in an era when prejudice and discrimination went largely unchallenged. They also experience twofold stigma around their sexual orientation and their age. For example, some older men perceive the gay community as predominantly youth-oriented (Bergling, 2004) and report feeling devalued and invisible as they grow older (Heaphy, 2007). Age-related stigma can therefore come from both outside and within the gay community. As they age, gay men also have increasing contact with health and aged care services, which may become new sources of discrimination (Cant, 2006; Hinchliff, Gott, & Galena, 2005), either from health professionals or from other patients. In addition, older men may encounter institutional discrimination more frequently, such as lacking the same rights as married heterosexual couples with regard to hospital visitation or inheritance from a deceased partner. Many do not have children and therefore also lack this as a source of support during their senior years (Beeler, Rawls, Herdt, & Cohler, 1999).

Positive Mental Health

Despite the many challenges of belonging to a doubly stigmatized population, not all older gay men experience mental health problems, even those who report recent experiences of discrimination (Lyons, Pitts, & Grierson, 2012). While it is important to examine factors for mental illness, there is also a need to examine factors for psychological health, or positive mental health (Keyes, 2009). By studying those who do well, potentially important insights can be gained into ways of promoting resilience and therefore preventing mental health problems. A need to examine what goes right, and not only what goes wrong, is one reason why research on positive mental health has flourished in recent years. Today, it is generally agreed that positive mental health forms a psychological construct that consists of both hedonic and eudaimonic components (Keyes, 2009; Ryan & Deci, 2001). The hedonic component involves frequent feelings of happiness and other positive affect. The eudaimonic component involves functioning well in day-to-day life, such as making decisions effectively or having a sense of meaning or purpose. Individuals who score high on measures of positive mental health have been shown to be less vulnerable to mental illness (Keyes, Dhingra, & Simoes, 2010) as well as a range of physical health problems (Chida & Steptoe, 2008; Diener & Chan, 2011; Keyes et al., 2010; Sadler, Miller, Christensen, & McGue, 2011; Siahpush, Spittal, & Singh, 2008; Veenhoven, 2008). Identifying factors related to positive mental health is therefore important to understanding ways in which individuals might achieve or maintain a level of psychological functioning that helps to protect against illness.

Despite research on positive mental health increasing considerably over the past decade, it has rarely been conducted among minority populations. Most of the studies that examine the mental health of older gay men have focused on factors for depression or anxiety (e.g., Masini & Barrett, 2008). We know of no studies that have specifically examined positive mental health among older gay men. However, work has been conducted on some aspects of positive functioning, such as crisis competence (Brown, Alley, Sarosy, Quarto, & Cook, 2001; Kimmel, 1980). A few studies have also reported factors related to well-being more generally (e.g., Grossman, 2006; Grossman, D’Augelli, & O’Connell, 2003; Lyons, Pitts, & Grierson, 2013a). These studies used relatively simple measures of well-being, such as single-item scales that asked participants to rate their overall well-being from “poor” to “excellent,” and found factors such as being in a relationship and having high levels of social support were significantly linked with greater well-being. These studies provide important indications of psychological health, but there is a lack of research on positive mental health. Factors that predict levels of psychological functioning among older gay men that are most protective against mental illness and other ill-health therefore remain largely unknown.

The Present Study

This article examines the mental health of a large national community-based sample of Australian gay men that specifically focused on middle-aged and older gay men, including those who were HIV-positive. The primary aim was to identify important factors for positive mental health. The short form of the Warwick-Edinburgh Mental Well-being Scale (SWEMWBS; Stewart-Brown et al., 2009) was used as a comprehensive measure of positive mental health, which incorporates both hedonic and eudaimonic aspects of positive mental health. Factors examined in this study included demographic variables, such as age, education, and income, and a range of potentially important psychosocial variables, such as those related to experiences of discrimination and social support. Although data for this study were derived from a longitudinal study, this article reports cross-sectional findings from the second wave only given that some of the key variables, such as the SWEMWBS, were not included in the previous wave.

Method

Participants

Participants in this study took part in the second wave of LifeTimes (Lyons et al., 2013a; Lyons, Pitts, & Grierson, 2013b), a national survey of the health and well-being of Australian gay men aged 40 years and older. In the first wave, 849 participants (72% of the total sample) provided a valid email address for the purposes of being contacted for future surveys. Of those contacted 1 year later, 430 participants took part in the second wave. These participants were from all areas of Australia, including regional and rural areas. Almost all reported their sexual identity as either gay or homosexual (99%). Eight participants reported some other identity or were transgender. Because this article focuses on those who identify as gay, these eight participants were excluded from the analyses. A further seven participants did not complete the main outcome measures for this study and were also excluded from analyses. This left a final sample for analysis of 415 gay-identified men.

Survey

The survey focused on broad aspects of health and well-being. In the part of the survey presented in this paper, participants provided the following information:

Demographics

Participants were asked to provide their age, highest educational attainment, employment status (full-time, part-time, not working), income, country of birth, and their current residential location (capital city, regional town or city, rural area). They were also asked whether or not they were in an ongoing relationship with either a man or a woman. Those who reported being in a relationship were then asked to indicate the number of years and months they had been in that relationship. Participants also indicated whether they had any children and whether they had any religious beliefs. Participants were then asked for their HIV status (positive, negative, or unknown).

Short Form Warwick-Edinburgh Mental Well-Being Scale (SWEMWBS)

After completing questions on demographics, participants completed the 7-item SWEMWBS; see Stewart-Brown et al., 2009). The SWEMWBS is specifically designed as a measure of positive mental health. It is one of the first scales to combine both hedonic and eudaimonic aspects of positive mental health into a single measure. Items include “I’ve been feeling optimistic about the future”, “I’ve been feeling useful”, “I’ve been feeling relaxed”, “I’ve been dealing with problems well”, “I’ve been thinking clearly”, “I’ve been feeling close to other people”, and “I’ve been able to make up my own mind about things.” The SWEMWBS is highly correlated with the original 14-item version of the scale (Stewart-Brown et al., 2009). The scale has been systematically validated among general populations and appears to be a highly robust measure of positive mental health (Stewart-Brown et al., 2009; Taggart et al., 2013; Tennant et al., 2007). The scale has also been used in previous studies involving older age groups (e.g., Gale, Dennison, Cooper, & Sayer, 2011). Scores for the SWEMWBS were computed using recommended procedures for the scale. Specifically, participants rated each item on a 5-point scale from 1 (none of the time) to 5 (all of the time). Scores on each item were then added to produce an overall score of between 7 and 35 for each participant. Although the SWEMWBS incorporates both hedonic and eudaimonic aspects of positive mental health, it is typically not treated as having subscales. In this paper we therefore report only on the overall score, as a general measure of positive mental health.

Psychosocial Variables

After completing the SWEMWBS, participants reported on a range of psychosocial variables. These variables were selected based on questions that were likely to relate to well-being, such as levels of social support and discrimination. Specifically, questions included the number of close friends participants had, whether or not they lived alone, and whether they had disclosed their sexual orientation to all or almost all people in their social networks. Two items were also included on discrimination. For these, participants were asked “When did you last feel you were treated unfairly as a direct result of your sexual orientation?” and “When did you last feel you were treated unfairly as a direct result of your age?” For each question, participants indicated whether or not this had occurred in the past 12 months, more than 12 months ago, or never. A dichotomous measure was computed to indicate whether or not participants felt they had experienced discrimination in the past year. Participants also indicated whether they believed the general public felt positively or not towards gay men and rated how much they felt a part of the gay community using four categories (“none”, “a little”, “some”, “a lot”). They were then asked about social support. Participants were again given four categories (“none”, “a little”, “some”, “a lot”). They were first asked a single question about how much overall support they felt they received in life (“In total, how much support do you feel you have in your life?”). This was followed by four additional questions that each specifically asked how much support they received from family, friends, a partner, and community or government support agencies.

Data Collection

The survey was conducted online between November, 2011 and April, 2012. Participants were originally recruited 12 months earlier when they completed the first wave of LifeTimes. Recruitment for the first wave was primarily through online advertising, including Facebook and websites that targeted gay men, such as those belonging to HIV/AIDS organizations. Participants in the first wave who provided a valid email address were then sent emails approximately 1 year later to invite them to participate in the second wave. Emails contained a direct link to the survey, where they were first provided with information about the study. After confirming that they had read this information, including a statement that their responses would be anonymous and kept confidential, participants then completed the survey. On average, surveys were completed in 16 min. Involvement in this study was voluntary, with no monetary or other incentives provided. The study was granted ethical approval by the La Trobe University Human Ethics Committee.

Data Analysis

A demographic and psychosocial profile of the sample was first compiled using descriptive analyses. Factors for positive mental health were identified using univariate and multivariate linear regression, with all demographic and psychosocial variables treated as categorical predictor variables and scores on the SWEMWBS as a continuous dependent variable. For these analyses, significant associations between the SWEMWBS and each demographic and psychosocial variable were first assessed with separate univariate linear regressions. Variables that were associated with the SWEMWBS at p < .10 in the univariate analyses were then entered into a multivariate linear regression. This commonly used cutoff allows for associations that are not quite significant, but which may become significant in a multivariate analysis (Hosmer & Lemeshow, 1989). Wald tests were used to assess the overall association between the SWEMWBS and each demographic and psychosocial variable. Standardized beta coefficients were computed to identify significant differences between the categories of each variable. All variables were treated as significant at p < .05, with analyses conducted using Stata 11.1.

Results

Sample Profile

Table 1 displays a sample profile for all predictor variables in this study. Almost all categories of each variable were well represented. Nearly one fifth of the men were born overseas, but almost all (99%) spoke English at home. A majority was aged 50 years and over, had a university education, worked full-time, and lived in a capital city. A little over half were in ongoing relationships, all of whom were in same-sex relationships. However, only 45% reported having a lot of support in their life, while 36% were living alone. A majority believed the general public’s feelings toward gay men were not positive and around a quarter reported experiences of discrimination in the past 12 months related to their sexual orientation. A majority also reported little or no connection with the gay community.

Table 1.

Sample Profile (N = 415).

	No.	%
Age
40-49	192	46
50-59	157	38
60+	66	16
Education
Secondary or below	115	28
Nonuniversity tertiary	133	32
University—undergraduate	78	19
University—postgraduate	89	21
Employment status
Full-time	243	59
Part-time	58	14
Not working	113	27
Income (Australian dollars)^a
0-19,999	58	14
20,000-49,999	99	25
50,000-99,999	155	39
100,000+	87	22
Country of birth
Australia	338	83
Overseas	71	17
Home location
Capital city	317	77
Regional town or city	67	16
Rural area	29	7
Relationship status
Not in an ongoing relationship	200	48
In a relationship of less than 5 years	72	17
In a relationship of more than 5 years	143	34
Have children
No	336	82
Yes	75	18
HIV status
Positive	82	21
Negative	307	78
Unknown	6	1
Have religious beliefs
No	190	46
Yes	225	54
Overall social support received
None	20	5
A little	74	18
Some	133	32
A lot	187	45
Number of close friends
0	20	5
1	21	5
2-5	217	52
More than 5	157	38
Live alone
No	267	64
Yes	147	36
Connection felt to gay community
None	80	21
A little	134	36
Some	110	29
A lot	49	13
Perception of public’s feelings toward gay men
Positive	194	47
Not positive	221	53
Experienced discrimination in past year related to sexual orientation
No	317	77
Yes	97	23
Experienced discrimination in past year related to age
No	278	67
Yes	134	32
Disclosure of orientation to social networks
To all or almost all people	320	77
To some or no people	93	23

Note: ^aAnnual pretax income. National median income for all employees at the time of the survey was AUD$45,240 (Australian Bureau of Statistics, 2010a).

Demographic and Psychosocial Factors for Positive Mental Health

Table 2 displays mean scores on the SWEMWBS for all demographic and psychosocial variables. Interitem reliability (Chronbach’s α) for this measure was .90. Scores ranged from 7 to 35, with higher scores indicating greater positive mental health. The overall mean for the sample was 24.8 and the standard deviation was 5.2. The distribution of scores was checked for skewness and was found to approximate a normal distribution. Separate univariate linear regressions were first conducted to identify whether each predictor variable was significantly associated with scores on the SWEMWBS. As displayed in Table 2, positive mental health was greater among men who were working full-time, F(2, 411) = 6.17, p = .002, had a higher income, F(3, 395) = 3.68, p = .01, and were in an ongoing relationship, F(2, 412) = 8.10, p < .001. On psychosocial variables, greater positive mental health was also significantly associated with receiving more social support, F(3, 410) = 57.96, p < .001, having more close friends, F(3, 411) = 19.56, p < .001, feeling connected to the gay community, F(3, 369) = 15.05, p < .001, believing that the general public’s feelings toward gay men were positive, F(1, 413) = 16.73, p < .001, and not having recent experiences of discrimination related to either their sexual orientation, F(1, 412) = 7.27, p = .007, or their age, F(1, 410) = 14.94, p < .001.

Table 2.

Univariate and Multivariate Factors for Positive Mental Health (N = 415).

		Univariate		Multivariate
	Mean	β	p	β	p
Age			.18		—
40-49 ^a	24.4	—		—
50-59	25.0	.06		—
60+	25.7	.09		—
Education			.39		—
Secondary or below ^a	24.5	—		—
Nonuniversity tertiary	24.5	.00		—
University—undergraduate	24.8	.02		—
University—postgraduate	25.6	.08		—
Employment status			.002		.22
Full-time ^a	25.5	—		—
Part-time	23.3	−.15**		−.09
Not working	24.0	−.13**		−.03
Income (Australian dollars) ^b			.01		.75
0-19,999	23.1	−.15**		−.04
20,000-49,999	24.3	−.08		.01
50,000-99,999 ^a	25.3	—		—
100,000+	25.7	.03		.03
Country of birth			.74		—
Australia ^a	24.8	—		—
Overseas	25.0	.02		—
Home location			.13		—
Capital city ^a	24.8	—		—
Regional town or city	24.0	-.06		—
Rural area	26.4	.08		—
Relationship status			<.001		.53
Not in an ongoing relationship ^a	23.7	—		—
In a relationship of less than 5 years	25.7	.14**		.05
In a relationship of more than 5 years	25.8	.19***		.06
Have children			.84		—
No ^a	24.9	—		—
Yes	24.7	-.01		—
HIV status ^c			.81		—
Positive	25.0	.01		—
Negative ^a	24.8	—		—
Have religious beliefs			.59		—
No ^a	24.7	—		—
Yes	24.9	.03		—
Overall social support received			<.001		<.001
None	16.0	−.46***		−.37***
A little	21.8	−.40***		−.30***
Some	24.5	−.25***		−.20***
A lot ^a	27.2	—		—
Number of close friends			<.001		.23
0	18.1	−.26***		−.09
1	22.6	−.08		.03
2-5 ^a	24.5	—		—
More than 5	26.4	.17***		.04
Live alone			.08		.06
No ^a	25.2	—		—
Yes	24.2	−.08		.10
Connection felt to gay community			<.001		.27
None	22.1	−.20***		−.03
A little ^a	24.6	—		—
Some	26.9	.20***		.08
A lot	25.9	.08		−.01
Perception of public’s feelings toward gay men			<.001		.32
Positive	25.9	.20***		.05
Not positive ^a	23.8	—		—
Experienced discrimination in past year related to sexual orientation			.007		.53
No ^a	25.2	—		—
Yes	23.6	−.13**		.03
Experienced discrimination in past year related to age			<.001		.19
No ^a	25.5	—		—
Yes	23.4	−.19***		−.07
Disclosure of orientation to social networks			.53		—
To all or almost all people ^a	24.7	—		—
To some or no people	25.1	.03		—

Note: Results from univariate linear regressions conducted for each predictor variable and a single multivariate linear regression involving those predictor variables that were associated with scores on the SWEMWBS at p < .10 in the univariate regressions. Variables that are significantly associated with scores on the SWEMWBS are in boldface. Categories that significantly differ from the reference category are indicated by asterisks. ^aReference category; *p < .05 **p < .01 ***p < .001; ^bAnnual pretax income. National median income for all employees at the time of the survey was AUD$45,240 (Australian Bureau of Statistics, 2010a). ^cOf those who knew their HIV status (N = 389).

A multivariate linear regression was conducted to identify critical factors for positive mental health. Predictor variables that were associated with scores on the SWEMWBS at p < .10 were entered into the regression. These variables included employment status, income, relationship status, social support, number of close friends, whether men lived alone, connection felt to the gay community, perceived public’s feelings toward gay men, and experiences of discrimination in the past 12 months. Of all these variables, social support was the only variable to emerge as a significant factor, with greater levels of perceived support associated with greater positive mental health, F(3, 333) = 17.85, p < .001. Overall model fit was R² = .32.

Social Support and Positive Mental Health

With multivariate analyses identifying social support as an important factor for positive mental health, we examined the degree to which particular sources of support were associated with positive mental health. Sources included support from family, friends, a partner, and community/government support agencies. Four variables for each of these sources of support were first entered into four separate linear regressions, with scores on the SWEMWBS as the outcome variable. As displayed in Table 3, men who reported receiving some or a lot of support from friends, F(3, 407) = 30.21, p < .001, family, F(3, 407) = 10.38, p < .001, or a partner, F(3, 403) = 8.32, p < .001, scored higher on positive mental health. Support from community or government agencies was not significantly associated with positive mental health, F(3, 406) = 1.72, p = .16.

Table 3.

Sources of Social Support and Positive Mental Health (N = 415).

		Univariate		Multivariate
	Mean	β	p	β	p
Support from family			<.001		.49
None	22.2	−.29***		−.08
A little	24.0	−.19**		−.08
Some	25.4	−.09		−.04
A lot ^a	26.4	—		—
Support from friends			<.001		<.001
None	17.3	−.39***		−.35***
A little	22.7	−.26***		−.21***
Some	25.4	−.08		−.07
A lot ^a	26.2	—		—
Support from a partner			<.001		.04
None	23.8	−.24***		−.13*
A little	23.1	−.13**		−.08
Some	24.3	−.13*		−.09
A lot ^a	26.4	—		—
Support from community or government agencies			.16		—
None	25.0	−.21		—
A little	24.4	−.21		—
Some	24.0	−.22*		—
A lot ^a	27.3	—		—

Note. Results from univariate linear regressions conducted for each source of support and a single multivariate linear regression involving those sources of support that were associated with scores on the SWEMWBS at p < .10 in the univariate regressions. Variables that are significantly associated with scores on the SWEMWBS are in boldface. Categories that significantly differ from the reference category are indicated by asterisks. ^a Reference category; * p < .05 ** p < .01 *** p < .001.

Support from friends, family, and a partner were then entered into a multivariate linear regression, with scores on the SWEMWBS as the dependent variable. Variables for the three sources of support were first checked for multicollinearity. No problems were detected. All variance inflation factors were below 5 and scores for tolerance were above .20 (O’Brien, 2007). As displayed in Table 3, receiving support from friends was the strongest factor for positive mental health, F(3, 392) = 16.84, p < .001. Receiving support from a partner was also significantly associated with positive mental health, F(3, 392) = 2.80, p = .04. However, support from family was no longer significantly linked with positive mental health after taking into account support from either friends or a partner, F(3, 392) = 0.81, p = .49. Overall model fit was R² = .21.

Discussion

This sample of middle-aged and older Australian gay men were more likely to display positive mental health if they were employed full-time, were in a relationship, felt supported, had many close friends, believed that the general public felt positively toward gay men, and did not report recent experiences of discrimination. However, in multivariate analyses, feeling supported emerged as the only factor once other factors were taken into account. Feeling supported by friends, and to a lesser extent from a partner, were two important forms of social support. Support from community or government agencies or from family was much less important. Although it is possible that those who are functioning well are better able to access the support they need, there is also evidence from previous research involving the general population that receiving high levels of social support can play a large role in psychological health (Cohen & Wills, 1985; Takizawa et al., 2006). Our findings suggest that social support may be particularly important to the psychological health of middle-aged and older gay men.

A few other studies have also found links between social support and indicators of mental health among older gay men (e.g., D’Augelli, Grossman, Hershberger, & O’ Connell, 2001). In one study, researchers found that older American gay men who reported high levels of support were less likely to have experienced depression and anxiety, particularly if they received support from friends (Masini & Barrett, 2008). It would appear from our study that receiving some or a lot of support from friends not only predicts a lower likelihood of mental illness, but also more optimal levels of psychological health. While friendships are important to just about anyone (Giles, Glonek, Luszcz, & Andrews, 2005; Michael, Berkman, Colditz, Holmes, & Kawachi, 2002), some recent studies suggest they serve a particularly crucial role for older gay men (De Vries & Megathlin, 2009). For example, while heterosexual men rely more on family than friends during older age, gay men appear to rely more on friends than family (Dewaele, Cox, Van den Berghe, & Vincke, 2011). Older gay men also attach greater meaning to their friendships, such that friends are often perceived as akin to family (De Vries & Megathlin, 2009). In some cases, friends may become a new “family of choice” (Pugh, 2002), especially if men’s relationships with their family of origin were undermined after revealing their sexual orientation (De Vries & Megathlin, 2009). It is also worth noting that many of these men are likely to have other gay men in their networks. Having a shared sexual identity and therefore similar life experiences can provide a strong foundation for giving and receiving emotional support, creating a sense of belonging or group membership, and coping with the effects of stigma and discrimination (De Vries & Megathlin, 2009; Grossman, D’Augelli, & Hershberger, 2000).

In addition to feeling supported by friends, there are other reasons why having strong social support more generally is likely to promote positive mental health. First, many gay men become vigilant around concealing their sexual orientation in public, which can lead to heightened stress (Meyer, 2003). Having strong support from those around them may allow these men to spend more time in social environments where they can be open with their sexual orientation and therefore have less time feeling stressed. Second, feeling supported may help to overcome loneliness. Particularly in older age, many gay men live alone (Lyons et al., 2013a). Although living alone does not necessarily mean feeling lonely, if they are also isolated from gay community networks or lack other forms of support, some may in fact feel lonely (Grossman et al., 2003) and loneliness is a common factor for poorer physical and mental health in older persons (Alpass & Neville, 2003; Luanaigh & Lawlor, 2008). Many older gay men also lack the support of children. Interestingly, however, we found no significant link between having children and positive mental health. It would appear from our findings that support from family is much less of a factor for positive mental health as other forms of support, which perhaps again highlights a tendency for older gay men to rely more on the support of friends.

That said, it is worth highlighting that variables in the present study collectively accounted for 32% of the variance in scores on the SWEMWBS. Clearly, additional factors beyond social support and the demographic and psychosocial variables we examined are also likely to predict positive mental health. More work is therefore required to identify other factors and to further understand the foundations of psychological functioning among older gay men. Also worth highlighting is that HIV status was not significantly associated with positive mental health despite previous studies showing that gay men with HIV are more likely to report depression and anxiety than those without HIV (Ciesla & Roberts, 2001). However, a recent study found that HIV-positive men were more likely to be receiving treatment for their mental health (Lyons, Pitts, & Grierson, 2012). This same study also found that after taking into account a range of psychosocial factors, including social support, there were no differences in the mental health of HIV-positive and HIV-negative gay men. In addition, large numbers of men in the present study were likely to have lived with HIV for many years. Some of these men may have overcome the most difficult challenges. For some individuals, facing and overcoming major life challenges, such as receiving a diagnosis for HIV, can even be a source of personal growth and therefore a potential path to positive mental health (Davis & Nolen-Hoeksema, 2009).

In all, findings from this study suggest that strategies for improving the mental health of older gay men need to include a focus on building strong support networks. There is now considerable evidence that older gay and lesbian adults have social and cultural needs that are different from their heterosexual counterparts (Pugh, 2005). Those who have an opportunity to work with this population, including psychologists, counselors, and relevant support organizations, are well placed for helping individuals to develop skills and strategies for accessing and maintaining social support. Older men who report having little or no support from friends may need particular assistance. Encouragement and support that helps these men to form new friendships, to strengthen existing friendships, or to locate environments and activities that enable an expansion of social networks may be especially important. Government or nongovernment programs that establish and promote social groups that bring together older gay men, to provide opportunities for developing friendships, may also be beneficial. Further research is also needed to better understand the kinds of friendships that are most beneficial (Guroglu, van Lieshout, Haselager, & Scholte, 2007).

More generally, research that examines factors and pathways to positive mental health among older gay men, and other sexual minorities, is also required for a more complete understanding of mental health in stigmatized populations. As mentioned earlier, having high levels of positive mental health, such as frequent feelings of happiness, establishing positive relationships, and making effective decisions, is not only protective of mental illness, but is also linked with better overall health, including physical health (Diener & Chan, 2011). There is also some evidence that greater psychological health is associated with less sexual risk-taking among gay men, such as having unprotected sex (Bancroft, Janssen, Strong, Carnes et al., 2003; Bancroft, Janssen, Strong, & Vukadinovic, 2003; Marks, Bingman, & Duval, 1998). How older gay men, and other sexual minorities, achieve positive mental health despite the challenges that come with belonging to a stigmatized minority (Meyer, 2003), may also provide an opportunity for gaining important insight into human strengths more generally.

Limitations and Future Research

There are some limitations to this study that need to be considered. First, this study was conducted online and may not have been available to all men in our target sample, particularly the oldest men who may be less likely to have Internet access. However, there is evidence that a large majority of Australians aged 60 years and older do in fact use the Internet (Australian Bureau of Statistics, 2010b). In addition, other studies that recruited older gay men, including some that used offline strategies, have demographic profiles that are not too dissimilar to that of our sample (e.g., Grierson et al., 2009; Lyons, Pitts, Grierson et al., 2012). For example, studies of Australian gay men generally report between 50% and 60% of participants in regular relationships (e.g., Holt et al., 2013; Mao et al., 2009; McLaren, Jude, & McLachlan, 2008), including one study that specifically examined older men (e.g., Prestage et al., 2009). This was also the case with our sample, in which 52% reported being in a regular relationship. However, some previous studies of older gay men obtained larger numbers of those aged 60 years and over than was the case in our study (Grossman et al., 2000; Grossman, D’Augelli, & O’Connell, 2001), perhaps due to the use of offline strategies, such as self-administered paper questionnaires. Although we found no significant age differences in positive mental health, we do not know whether this would be the case for the oldest old, such as men in their 80s and 90s. Studies that specifically recruit much older men are therefore recommended. That said, it is worth noting that gay men can be difficult to reach in large numbers and conducting surveys online is one feasible way of obtaining a large, national sample. To maximize generalizability, future research could consider recruiting participants through a combination of online and offline strategies, such as offering mail-out questionnaires to those without Internet access.

Second, as suggested earlier, findings reported in this article were from cross-sectional data. We were therefore unable to determine directions of causality. For example, on the one hand, men who are psychologically healthy may find it easier to establish and maintain various forms of social support. On the other hand, those with high levels of support are more likely to become or remain psychologically healthy. Only longitudinal analyses can assess these and other causal directions, which we intend to investigate in future work. That said, given that previous studies found social support to promote psychological health, it would be surprising to find longitudinal studies of middle-aged and older gay men that did not identify social support as a prospective predictor of mental health.

Third, this study focused on gay men aged 40 years and older. At present, we do not know whether our findings also apply to other sexual minorities, such as lesbians or younger gay men. Some previous studies of depression among gay men of all ages identified social support as a protective factor (e.g., Mao et al., 2009). However, further research is required to determine ways in which particular sources of support, and other possible health-promoting factors, facilitate positive mental health in a range of sexual minorities as well as other stigmatized populations. It is also worth noting that HIV-positive gay men are likely to have challenges and experiences that are specific to living with HIV, such as HIV-related stigma and issues around HIV treatment. Our study did not examine these in sufficient detail for reporting in this article. There are, however, other studies that report on factors related to the well-being of HIV-positive gay men (Lyons, Pitts, & Grierson, 2012; Lyons, Pitts, Grierson, Thorpe, & Power, 2010), but studies that specifically examine positive mental health within this population are needed. Finally, the present study examined positive mental health in a broad sense, through the use of the SWEMWBS. Future studies may wish to examine specific aspects of positive mental health, such as positive affect or social well-being (Keyes, 1998). Having such data may provide further insight into the psychological health of middle-aged and older gay men. Additional factors not examined in this study, such as specific psychological coping strategies, might also be linked to positive mental health and may provide further guidance for strategies that seek to overcome the effects of stigma and to promote psychological health.

Conclusion

In this large national survey of middle-aged and older Australian gay men, receiving social support was found to be an important factor for positive mental health. Those who reported high levels of social support were more likely to be psychologically healthy, especially if they received support from friends. As demonstrated in previous work, high levels of psychological health are linked to a range of other health and well-being outcomes, such as lower incidence of mental illness and better physical health. Strategies that promote positive mental health, in addition to treating mental illness, may therefore be crucial to preventing a range of future health problems. To support such strategies, further research is required to investigate how exactly particular sources of support relate to positive mental health in stigmatized minorities and to identify other important factors. For now, our findings provide some indications that health agencies that assist older gay men to establish strong support networks may help to promote and maintain psychological health, and therefore reduce some of the health risks of belonging to a stigmatized minority.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by funding from the Australian Government Department of Health and Ageing as part of a Health Surveillance Fund grant awarded to Professor Marian Pitts.

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