Individual and Social Factors Related to Mental Health Concerns among Bisexual Men in the Midwestern United States

Abstract

Research has not yet explored the potential impact of social stress, biphobia, and other factors on the mental health of bisexual men. In-depth interviews were conducted with a diverse sample of 75 men who engaged in bisexual behavior within the past six months. Interviewers explored potential mental health stressors and supports. Many participants reported personal and social challenges associated with bisexuality, which in turn influenced their mental health. Reported instances of stigma toward bisexuality, from both homosexual and heterosexual individuals, impacted participants’ feelings regarding their own sexualities. Isolation was also commonly reported. Programs are greatly needed that focus on the specific mental health and other concerns voiced by these men. Based on our study findings, such programs should emphasize self-acceptance, social network and community building, and ways to maximize available social support, similar to community-level empowerment interventions that have shown success among gay-identified men.

INTRODUCTION

Studies on mental health among behaviorally and self-identified bisexual men in the United States (U.S.) have been largely absent from previous research, including studies that examine the relationship of sexual orientation and identity with mental health. Researchers who have explored social stress theory, specifically the concept of minority stress, suggest that “sexual minority individuals” are challenged by stigma, prejudice, and discrimination and often experience negative mental health outcomes as a result (Kelleher, 2009; Meyer, 1995, 2003; Zamboni & Crawford, 2007). However, in these studies, bisexual individuals are most often subsumed under the label of “gay, lesbian and bisexual (GLB).” Indeed, most previous research on health issues among “GLB,” “gay and bisexual,” and “same-sex attracted” samples has not distinguished bisexual men from gay men. The few studies that have examined bisexual men’s mental health concerns separately from both homosexual and heterosexual men have consistently found higher rates of mental health issues among bisexual men when compared with both homosexuals and heterosexuals (Jorm, 2002; Paul, 2002; Robin, 2002; Udry, 2002). As yet, these findings have emerged from a small number of primarily quantitative studies and have not been explored in terms of the context and meaning of mental health concerns among bisexual men themselves.

The personal and social circumstances of bisexual men are markedly different from gay men, including both mental health stressors and supports (Dodge, Reece, & Gebhard, 2008; Jeffries IV & Dodge, 2007; P. C. R. Rust, 2002). As demonstrated with gay men, however, it is reasonable to suggest that factors associated with minority stress may create particularly taxing life situations for bisexual men that relate to a number of negative health outcomes. Given the diversity of bisexual men, and the ways in which they experience and express their sexualities, it is difficult to isolate global factors that may be related to increased risk of mental health problems. Age, race/ethnicity, socioeconomic status, geographic location, and other demographic considerations are all interact with men’s experience and expression of their sexuality (Jeffries IV, 2009; Lewis, 2004; Saewyc et al., 2009). In addition to these sociodemographic factors, bisexual men in numerous contexts may face unique mental health concerns for reasons specifically related to bisexual behavior, orientation and identity. “Biphobia,” in particular, may generate pervasive distress linked to adverse mental health outcomes.

Biphobia is characterized by the stigma and discrimination that bisexual individuals experience from both heterosexual and homosexual individuals on the basis of their bisexual orientation and/or identity (Angelides, 2001; McLean, 2008; P. C. R. Rust, 2002; Welzer-Lang, 2008). In recent decades, the concept of biphobia has been highlighted extensively in lay, and more recently scientific, literature. In a U.S. random digit dialing sample, heterosexual individuals expressed more negative feelings toward bisexual men than all other religious, racial, ethnic, political, and sexual minority (including gay men) groups except injecting-drug users (Herek, 2002). In a community-based sample, Rust found that bisexually-identified men report being stereotyped as “confused,” in denial, or in transition to eventual homosexual or heterosexual lives by gay men and lesbians (P. C. Rust, 2001). Additionally, bisexual men report a lack of specifically “bisexual” space separate from other sexual minority communities and a lack of support and responsiveness from public health infrastructure. Consequently, bisexual men are at risk of social isolation because of lack of social support from any source, including the gay community. Indeed, Weiss (2004) has argued that even with the emergence of nominally inclusive lesbian, gay, bisexual, and transgender (LGBT) services, in practice, bisexual men remain largely invisible or treated as gay males.

Thus far, studies have not explored the role that bisexual men’s involvement in a wide range of communities may play in promulgating or reducing social stress. “Community” can be defined as a unified body of individuals who often share common characteristics while living together in a larger society (Israel, Schulz, Parker, & Becker, 1998). Individuals in communities interact with each other based on their proximity, and shared norms, behaviors, values, and identities. A sense of belonging to a social space or community can be significant for individuals since their ability, or inability, to navigate and access resources available in that community has a host of repercussions on their own individual experience. The level of community involvement and social support may impact the health and well-being of bisexual men.

As with other groups, stigma toward bisexual men from both heterosexual and homosexual communities may be a contributing factor leading to social isolation and poor mental health (Pescosolido, Martin, Lang, & Olafsdottir, 2008). Given the scarcity of information specific to bisexual men’s mental health, more in-depth data are needed to define their concerns and needs, particularly common themes across different cultural context within specific areas in need of intervention. The setting of our study was recently ranked 50^th out of 50 states by the Centers for Disease Control and Prevention (Atlanta, Georgia) in terms of federal funding for public health prevention programs. The purpose of this study was to examine a wide range of mental health concerns, with a focus on community involvement, among a diverse sample of bisexual men in an understudied and underserved area of the Midwestern U. S.

METHODS

Sample Construction

Definition of “Bisexual”

As the primary focus of our study was on HIV/STI risk and transmission, our sample was composed of biological males from the study area who engaged in recent bisexual behavior. Nearly all studies to date that have focused on mental health concerns among bisexual individuals have done so among self-identified bisexuals; thus, this study is novel in that it focuses on behaviorally bisexual men. To ensure relevance in terms of bisexual behaviors and risk, we recruited a sample of men who engaged in oral, vaginal, and/or anal sex with at least one male and at least one female partner during the past six months, regardless of sexual identity. Research studies have varied greatly in the time period for which sexual behavior may be classified as “bisexual,” but we chose six months as the duration defining bisexual behavior to obtain a more accurate account of participants who are currently behaviorally bisexual (and therefore distinct from currently behaviorally homosexual or heterosexual).

Demographic Characteristics

Based on the previous studies, more data are currently needed from bisexual men of diverse ethnic groups (Dodge, Jeffries, & Sandfort, 2008; M. Muñoz-Laboy & Dodge, 2007). Previous work suggests that race/ethnicity, perhaps as a surrogate of socio-cultural setting, is intricately linked with sexuality (Lewis & Kertzner, 2003). Thus, we recruited a diverse sample in terms of race/ethnicity. For the purposes of this study, the term “Non-Hispanic White” included individuals of European-American ancestry. The term “Non-Hispanic Black” included African-American men, Afro-Caribbean men, and other men of African descent. The term “Hispanic” referred to an individual of Latin American ancestry, regardless of racial background. All categorizations of race/ethnicity were based on self-identification. Equal numbers of non-Hispanic Black (n = 25) and non-Hispanic White (n = 25), and Hispanic men took part in this study. One participant who identified as “Asian” also participated. Interviews were conducted in English (n = 60) or in Spanish (n = 15). In this paper, we sought to identify common themes for mental health concerns for men across various racial/ethnic groups as comparisons of our participants experiences of their bisexuality across cultural contexts have been published elsewhere (Martinez, et al, 2011).

In addition to race/ethnicity, a broad age group was warranted since sexual relationships and risk behaviors among bisexual men may differ substantially based on age. More information from older bisexual men is especially needed, particularly those who may be married or in long-term relationships with women, given the lack of scientific data regarding these men. As we were not certain of the age distribution of bisexually-active men in the study setting; our sampling criteria was flexible in order to accurately “map” this community. We anticipated recruited men from a wide age range (18 years old and over) and paid close attention to not over-sample any particular age group.

As with much qualitative research, our sample size (N=75) was based on achieving saturation or redundancy. We estimated that 25 interviews within each racial/ethnic group would meet that goal. The sample represented an estimated minimum number of diverse participants needed to achieve redundancy, and also acknowledged the time needed for adequate data collection, transcription and analysis. All study protocols were approved by the Institutional Review Board of the authors’ academic institutions.

Participant Recruitment

Recruiting men who were both representative of the range of experiences of bisexual behavior and diverse in terms of relevant demographic and behavioral characteristics required an eclectic sampling plan. Thus, we combined clinic-based recruitment, Internet-based recruitment, and participant referral. Initial participants were recruited from the patient population of Indianapolis, a sexually transmitted infections (STI) clinic operated by the county health department. We chose this clinic for recruitment for several reasons. First, the population of at-risk persons represented by an STI-clinic population was of direct interest in terms of public health objectives and HIV/STI risk reduction efforts. Second, this population had sufficiently high self-reported bisexual behavior to allow for evaluations of our study aims. Third, the clinic serves a multi-ethnic community, making it possible to recruit a diverse sample of participants. Fourth, although STI clinic samples are well represented in research literature related to STI risk behaviors, relatively little research directly addresses the issues specifically pertinent to male bisexuality. Most of the existing research is limited to assessments of prevalence STI among MSM, regardless of whether risk behaviors with female sexual partners also occurred during the same period of time.

Because few physical venues geared specifically toward bisexual men exist, recruitment from Internet sites further diversified the types of men we were able to recruit for this study. Increasing numbers of MSM, including bisexual men, use Internet chat rooms to meet sexual partners. In a recent assessment of the sexual behaviors of MSM in the study area, researchers found that approximately 30% reported using the Internet for social and sexual purposes and that, as with other samples, men recruited via the Internet were more likely to self-identify as bisexual and report engaging in bisexual behavior during the previous year than those recruited from gay-identified venue (Satinsky et al., 2008). Recruiting potential participants from a variety of Internet sites ensured a diverse cross-section of bisexual men.

The third recruitment strategy relied on participant referral. Previous qualitative research experience with Black bisexual men and other sexual minority individuals has informed us that respondents generally appreciate the opportunity to talk about their life experiences. Respondents often share very personal information that they have never disclosed with another individual before; indeed, some feel a great sense of relief after having done so. With this positive research experience, many respondents were willing to tell friends and acquaintances about the study. Thus, we distributed recruitment materials to study participants. Each respondent who agreed to assist with recruitment was given three to five postcards to distribute to members of his social network who fit the eligibility criteria. This method of recruitment was particularly important given the sometimes secretive social and sexual networks of bisexual men, as they may not be easily recruited from traditional venues where exclusively homosexual men congregate.

Study Procedures

All participants were required to give written informed consent to the study procedures, including digital audio-recording, before the interviews take place. We conducted interviews at locations that were both convenient and comfortable to the participant. Most interviews were conducted at a private office at Indiana University School of Medicine or one of our partner community-based organizations. Other locations included public settings that offered a reasonable level of privacy and were conducive for digital audio recording.

Data Analysis

Processing the qualitative interview data occurred in several standard stages of organization, analysis, and reflection (Creswell, 2003). Text data served as the basis for analysis. The thematic analysis we conducted highlighted the themes embedded in the texts in a manner that is sensitive to their subjective meanings. The hallmark of such semantic analysis is the careful fragmentation and coding of the data, involving organizing the data into “chunks” before bringing meaning to those “chunks” (Rossman & Rallis, 1998). The texts of all interviews were reviewed and coded systematically by the study team. All text data were be coded and analyzed using NVivo, a widely-used computer program that greatly facilitates the sorting, organizing, and relating of coded segments of textual data.

Data organization, analysis, and interpretation took place in several stages. First, a “coding practicum” occurred in which three coders worked jointly on the first five transcripts to identify ambiguities or differences of interpretation among the coding team. The coders worked independently on the same transcripts and compared their coding decisions in weekly coding meetings until all transcripts are coded. Last, a consultant who is an expert in qualitative research methods applied to sexual health research reviewed each of the coders’ work at several points to ensure that codes are being applied consistently.

A codebook for qualitative analysis was constructed which consisted of a theoretically-informed manual of codes and sub-codes, defined by specific definitional criteria that allows for systematic textual coding. By coding textual data using a codebook that defined all codes of interest using a hierarchical structure much like a conceptual outline, large volumes of data were summarized using a manageable number of central “themes,” and the interrelationships among them could be efficiently examined. During a series of team meetings, the analytic codebook was developed and used iteratively for coding purposes. The codebook was derived from a systematic review of the interview transcripts as they were transcribed and was updated as needed throughout the course of the data organization. Using the codebook, emergent themes and patterns in the data related to the study aims were identified and documented by the individual investigators.

After the initial mapping of themes, the researchers began the process of collaborative interpretation of the coded themes. Emergent ideas were compiled and compared among investigators as themes are compared. The list of topics was collaboratively organized into a matrix of themes and sub-themes. By structuring the themes in this way, the team was able to develop a scheme that was used for analyzing all the narrative data in a systematic way. The research team met on a regular basis to review the interpretation and continuous development of the thematic matrix.

RESULTS

Participant Characteristics

A total of 75 men participated in the study. The average age was 33.3 years (SD = 11.5), with a range from 19 to 70 years old. In terms of race/ethnicity, among White participants, 24 identified as “Caucasian American” and one as “Hungarian.” Among Black participants, 21 identified as “African American,” two as “Black/Native American,” one as “Black/Somali,” and one as “Black/Asian.” Among Hispanic participants, 13 identified as “Mexican,” four as “Venezuelan,” one as “Brazilian,” one as “Cuban,” one as “Dominican,” one as “Honduran,” one as “Puerto Rican,” one as “Salvadoran,” one as “Spanish,” and one as “Mixed.” Table 1 provides information on other demographic characteristics of this sample.

Table 1.

Participant Characteristics (N = 75)

	n	%
Age
19 - 24	24	32.0
25 - 29	12	16.0
30 - 39	13	17.3
40 - 49	21	28.0
50 +	5	6.6
Race/Ethnicity
Black	25	33.3
Latino	25	33.3
White	25	33.3
Living Situation
Living Alone	18	24.0
Living with Someone	57	76.0
Marital Status
Single	55	73.3
Married	13	17.3
Separated	3	4.0
Divorced	4	5.3
Children
None	41	54.7
One	15	20.0
Two	10	13.3
Three or more	9	12.0
Highest Level of Education
Less than High school	16	21.3
High school/GED	22	16.0
Some College/Associate Degree	16	21.3
Bachelor Degree	14	18.7
Graduate School/Master’s Degree	5	6.7
Professional Degree	2	2.7
Employment
Yes	56	74.7
No	19	25.3
Monthly Income
< 1,000	31	41.3
1,000 - 1,999	20	26.7
2,000 - 2,999	13	17.3
3,000 - 3,999	3	4.0
>4,000	8	10.7

Individual Struggles with Acceptance of Engaging in Bisexual Behavior

Bisexuality may be a difficult construct for many people to deal with given the binary sexual roles that are socially prevalent in the U.S. (including social expectations of monogamy). Many participants alluded to a difficulty in accepting their own bisexuality, which may influence negative mental health issues among this group.

Yes, but I mean not personally but I think some people who do engage in sex with both males and females could very easily have those troubling thoughts of not knowing whether they’re bisexual or whether they’re fully homosexual or fully heterosexual. (Participant 8, 43, White)

This idea was further reflected by comments suggesting that some men may not have determined their own bisexuality and were struggling with the process.

I do think that other physical and mental health issues are big issues. For example, it was really hard for me to confront the fact that I liked to have sex with men and women. (Participant 52, 24, Latino)

These comments illustrate the potential for poor mental health among this population as they search for validation of their sexuality in a culture that does not fully recognize their existence. Several men raised the issue that being pressured to select a sexual identity as either heterosexual or homosexual could lead to mental health concerns.

It can. I personally think it can. It can be stressful and might lead to depress[ion]… (Participant 25, 28, Latino).

This difficulty associated with a lack of acceptance of bisexuality was also reported with leading to well recognized indicators of risk for mental health, including low self-esteem and self-worth. This was a common theme derived from many of our participants.

It used to make me feel more vulnerable and made me do risky things that wasn’t conducive of me loving me. That’s when maybe I’ll allow somebody to penetrate me with no condom because I don’t love myself today because of the negative voices speaking … (Participant 31, 46, Black)

This respondent suggested that a lack of acceptance of his sexuality resulted in low self-esteem and this directly increased his participation in risky sexual behaviors. Additionally, some men believed that bisexual men may have more sexual partners and participate in higher risk activities as a coping mechanism.

They look – oh, well, this guy wants me, and this girl wants me, so now I feel I’m wanted, you know? And it gives them that sense of being wanted, and makes them feel better about themselves. (Participant 63, 27, White)

Men reported that decreased sense of self-worth or low self-esteem was due to the stigma and shame that make it more difficult for men to discuss openly their bisexuality and to feel secure within this identity label. Overall, for many men there appeared to be difficulty with self-acceptance of bisexuality that was closely linked to one’s age and racial/ethnic backgrounds. Those men, who were most comfortable with accepting their own bisexuality were more often White and younger. Participant 126 (White, 26) indicated that there were a few family issues in relation to his bisexual identity, but he expresses that he has no problem with that “It’s fine.”

Interviewer:	Have you ever been having trouble with the bisexual part?
Participant:	No.
Interviewer:	Never?
Participant:	I mean maybe with my parents a couple of times but that’s it.
Interviewer:	And how have you been able to cope with this?
Participant:	It’s fine. I don’t mind at all. It doesn’t bother me.
Interviewer:	And with the HIV?
Participant:	That’s just like I said accepting it and being accepted. That’s the hardest thing about that.

Compartmentalization of Sexuality

For many of the behaviorally bisexual men we interviewed, it was often difficult to accept their own bisexuality because of perceptions of “morality” and bisexual behavior, stereotypes of bisexuality, and lack of acceptance of bisexuality from larger society. Further, these themes point to strategies that bisexual men employed, specifically the compartmentalization of their sexuality into “heterosexual” or “homosexual” based upon the setting they were in or attempts to distance themselves from the stereotypes associated with bisexual men, as a way to be able to function within social settings.

One mechanism for coping with bisexuality was to attempt to mirror socio-cultural norms by enacting either “straight” or “gay” identities or compartmentalizing sexuality into binary roles, as found in another recent study of Latino bisexual men (M. A. Muñoz-Laboy, 2008). Many of the participants, across racial/ethnic groups, described feelings of separating their sexual self into two parts not only to others, but also to themselves.

For example, when I am with somebody I feel like I am doing something wrong, like it is not me, like homosexuality is bad. (Participant 51, 21, Latino)

Not only does this participant describe having difficulty accepting his bisexuality, specifically sexual interactions with men, he also suggests that what he is doing is “not him.” This compartmentalization of sexual identity was common for many of our participants, as further indicated by Participant 48 (Black, 30):

I mean I understand the whole socially acceptable thing because I know my parents would not accept me bringing a guy home, so I don’t throw it into anybody’s face that I think can’t handle it. But as far as my friends that can handle it, I let them know that you need to deal. I mean I’m going to be who I am and I’m going to be who I’m with.

These participants describe how they allowed labels to be applied differently depending up the context, often with homosexual behaviors having a negative connotation for others.

It’s a little bit disconcerting. It’s a little bit like I try and push myself in that direction at that time. You try and forget the other part. You close your mind off to it. I don’t know how else to describe it. You just, I don’t know that you actually ignore the other side but that’s about what you do. (Participant44, 59, White)

…not everybody is so open as they should be, and I think that that is one of the biggest problems, is – because if everybody accepted it, and understood it, and there was no stereotypical, you know what I mean, those stereotypes, I think it would make it a lot easier, definitely, for people to come out, so to speak. (Participant 56, 27, Black)

While one participant expressed not having any issues in terms of his feelings regarding being bisexual, unequivocally stating:

No. I’m not ashamed of it. (Participant 5, 30, White)

He also explained that compartmentalization of his sexuality as bisexual, gay, or straight based upon the expectations of a give context:

Yes, I use whatever makes people feel most comfortable at the time in which I am there. So like if I’m inside of a gay bar, and they’re like are you gay. Yes, that’s what the fuck I am and then I walk off and they’re just like oh. And they think or they’re like or are you bisexual because that’s going to get you to go ahead and you ain’t going to want to talk because well hell, bisexual people, they got a lot of issues but the thing is I mean honestly, the way I look at it, that’s what I’ve actually found out too that basic generalization of what they say about bisexual people is that they are very dramatic and have all kinds of fucked up things happen. If they do, that’s only because they let it happen. It’s not due to the fact of their sexuality. It’s in fact due to their fucking mindset in which they have. (Participant 5, 30, White)

Not only does this participant describe difficulties in being bisexual based upon social expectations within a certain setting, as well as a desire to maintain the comfort of others within the setting, but possible reasons for shying away from identifying as bisexual in any situation because of the negative stereotypes associate with this label.

Reluctance to Disclose Bisexuality

These stereotypes and situations also explain why many of the participants reported a fear of disclosure, particularly to family members. In many interviews, issues arose during discussion of bisexuality and family, with men expressing intense fears of losing their family members, especially children, if their bisexuality was “discovered.”

Interviewer:	And with the family, are you just worried about like your kids finding out?
Participant:	My kids, yeah, extended family, et cetera.
Interviewer:	And you’re worried because you don’t want them to judge you?
Participant:	Yes … with me is with my wife, if she finds out about the other guys … with my kids, that’s a major issue. (Participant 44, 59, White)

Similar to others, many Latino men described feelings of having to conceal their bisexuality in order to maintain social relationships with their families.

But when I was in Mexico, I would tell myself “It has to be a woman, it has to be a woman,” because I was afraid of my family, I was afraid to tell them and that they would find out and I had to do what everyone else was doing; or perhaps, repress a part of me for another part. (Participant 50, 22, Latino)

This participant expresses concern about his family discovering his bisexuality, in particular his sexual desire for men, as he indicated he had to “repress” those desires, possibly out of fear of losing familial ties, which has been found to be important within Latino cultures (M. Muñoz-Laboy et al., 2009; M. A. Muñoz-Laboy, 2008). This concern over disclosure to family was explicitly tied to these men’s concerns, as explained by another participant:

“Most of the people that I know have sex with both men and women but again, they will never go by the label. They do everything on the down low or when they are drunk.” (Participant 52, 24, Latino)

This participant continued on to explain his own experience with his family learning of his bisexuality:

When I came out to my mother, they wanted to send me back to Mexico and get a hormone treatment to be ‘changed.’ I did not want that at all, I knew what I wanted and I knew that no one could change me. My mother sent me to Guadalajara and they paid for my flight there, once I got there, my sister took me to a doctor without my consent and knowing the situation. Once I found out about this trick, I got really upset and did not decide to proceed with the medical treatment. (Participant 52, 24, Latino)

This story expresses the feelings conveyed to some bisexual Latino men by their families compounding fears of not only family ties being broken but active attempts of the family to change the outward “appearance” of their son in order to, as they see it, correct outward gendered appearance to match the perceived gender of their sexual orientation.

Loss of familial ties was not the only feared consequence if others were to find out. Several men indicated that because of their status, or being well known in their communities, others finding out about their sexuality would be problematic because others are judgmental:

I mean at the same time, [pause] the reason is, I’m known from where I’m from. So really, I keep everything strictly on that kind of level. I don’t things get out so really I can’t put myself into something like that because of my status. (Participant 8, 22, Black)

This participant continues to elaborate on his fear of others finding out by indicating that those around him are judgmental, “It’s just coming out in the open is a big step of doing that so that’s the people that I’m around, they are very judgmental, especially of Black bisexual men.” While he expressed concerning of members of his community finding out, the primary issue seemed to be his family indirectly finding out from others because of their shared community. Some men indicated that if they were to be “found out” that would literally lose everything:

No, no, because I’m, again, have to be extremely discreet because if it got out, I would lose, I literally would lose everything, my job, my wife, my kids, my home, everything. (Participant 75, 34, White)

Some men expressed concern, in some instances because of lived experience, of the threat of violence if others were to find out about their bisexuality. On man described a situation in which he was leaving a gay bar and was physically attacked,

“I’ve been beat up, you know? Once – one time, I left a bar on the outskirts of [town]. I can’t even remember what bar it was, but I got jumped pretty badly.” (Participant 43, 27, White)

Another participant elaborated on the concern of physical violence, particularly from heterosexual individuals, but indicating a possible fear of those close to him may become perpetrators if his sexuality were discovered:

…but there’s also – I think that there’s risk of gay bashing violence, or whatever. If there’s a guy who’s dabbling, who’s running with straight people, and he’s going back and forth, and all that, I mean, it’s – yeah, I think that’s dangerous behavior to an extent, I do. (Participant 45, 41, White)

While these participants may be justified in their concern over being physically harmed, it appears to be different than simply being labeled as gay or homosexual. “Going back and forth,” between female and male partners, could have particularly harsh consequences. However, while men identifying as gay often create new concepts of family and find different modes of social support and protection, among bisexual men the lack of a visible and coherent bisexual community, as well as the stigma and discrimination experience in both heterosexual and homosexual communities, may result in higher levels of mental distress.

Lack of a Community and Perceived Bisexual Spaces

A large proportion of the men interviewed expressed feelings of loneliness and “not belonging anywhere” as a bisexual man.

People being bisexual, they are really depressed because they feel that they don’t belong to any group.” (Participant 28, 34, Latino)

Men expressed two interrelated issues regarding lack of belonging to a community. The first was a fear of disclosure, as described above. The second issue involved a genuine lack of a community to which to belong.

I’m sure there’s other people out there like me because people get frustrated in their situation but is it a formal community? I don’t know. I think there’s probably an unspoken community. But I can’t find it.” (Participant 66, 57, White)

This description of an “unspoken community” described the lack of visibility and cohesiveness of a bisexual community. This idea was further illustrated by several other participants:

“What kind of people, you mean? Bi people but I don’t think there’s like community – well, I don’t know.”(Participant 42, White, 23)

This participant goes a step further suggesting a bisexual community may not exist at all or it does he is unaware of it. This belief was most common among participants with most specifically indicating lack of community.

“I don’t’ know any bisexual community in Indianapolis like I told you so I don’t know if there is any bisexual community. (Participant 15, 34, Latino)

If a community did exist, a small number of men reported not wanting to be associated with it for fear of negative outcomes associated with being labeled as bisexual. However, in the absence of such communities and spaces, it is difficult for men to derive the level of social support needed by all marginalized groups of people.

Participants reported not only a lack of ability to meet other bisexual men in a social context but also an apparent lack of space for this group to come together. This may constitute a major factor as to why all men perceive a lack of community,

Bisexual bar? I mean I feel like I go to gay bars and to some straight bars too, but bisexual, I cannot think of any bisexual bar that I go to.” (Participant 14, 25, White)

No, I haven’t been to a bisexual location. I wouldn’t know where a bisexual location is. (Participant 39,45, Black)

Participants were asked questions concerning integration into heterosexual, homosexual and bisexual communities and spaces within those symbolic communities. Some men felt a greater sense of belonging in heterosexual spaces, some in homosexual spaces, some in both spaces, and some men felt they did not belong anywhere.

While some men indicated feelings of belonging in heterosexual spaces, others felt they did not belong in heterosexual spaces and some felt belonging in homosexual spaces. Participant 58 (29, Latino), when asked about heterosexual space, responded:

INT:	Do you ever go to any heterosexual – well, you go to any heterosexual bar?
R:	Um hmm. [Indicates yes].
INT:	Do you feel like you belong to those places?
R:	No.

However, only a few men specifically indicated that it was because they did not feel belonging in heterosexual spaces that they sought out gay spaces.

In the case of gay spaces, men who said they felt belonging indicated they felt connections to other men, they were known by other people, or they felt similar to the individuals in those spaces, or as Participant 46 (41, White) indicated: “Because they’re like me.” Participant 38 (53, White) indicated he felt comfortable and connected in gay spaces because:

Some of them, they know me and they know I’ve been around here doing the work that I do so they all know me from the work that I do.

Most individuals expressed feelings of not belonging in either heterosexual or homosexual spaces, and this had ramifications for their overall wellbeing.

I mean sometimes I don’t think I fit in like with socially, with gay, social life, gay sometimes, I feel like or maybe I feel like I’m falling or whatever. Sometimes I don’t belong to them and when I go to the straight area, I feel that both I don’t belong to them sometimes. (Participant 1, 33, Black)

However, some men identified as belonging to either homosexual or heterosexual space or they felt comfortable in any setting. Participant 28 indicated he did not belong anywhere in particular, but felt comfortable in most situations:

Not really. I mean I don’t know. I go wherever I feel comfortable (Participant28, 34, Latino).

Another participant indicated that space he utilizes is influenced by the people he is with, but also that those two worlds don’t mix, which relates to the theme of compartmentalized identities.

Just depends on the group of friends that I’m with. If I’m with heterosexual friends, then I’m in the heterosexual place. If I’m with gay friends, then I’m in the gay place, with a gay group. So sometimes those friends don’t mix (PARTICIPANT13 42, Black).

This could possibly be equivalent to gay men who are not “out” concerning their sexuality and operate in heterosexual and homosexual communities. However, what is important about feeling belonging anywhere is it seems to be more similar to belonging nowhere, than not. Many men who indicated they could fit in anywhere often described not really feeling belonging to any community, but could be comfortable anywhere. This theme was common among many of the men in this study, either they felt they belonged in heterosexual or homosexual spaces or they felt uncomfortable leaving that space or felt comfortable in any space, even in the absence of a sense of belonging. More importantly with those men who felt comfortable anywhere, this was often due to their compartmentalization of their sexual identity and separation of homosexual and heterosexual social networks, with few men feeling they were actual able to bridge these two worlds. This was also reflective in one explanation of why a participant sometimes felt uncomfortable in gay spaces.

You do and you don’t. I mean, me personally, I thought I can go in, and you know, talk to them, or talk to anybody in there and be fine, but at the same time you can kind of tell some of the gay people are like, “What is this straight man doing in my bar?” So, I feel comfortable going in there, but some people don’t feel comfortable with me being in there, I guess I would say. (Participant 16, 22, White)

This participant indicates that he is not personally uncomfortable; rather the discomfort of others in the space due their perception of his sexuality brings about the lack of a sense of belonging he feels within the gay community and gay spaces.

DISCUSSION

In health related research and practice, it is crucial to differentiate between bisexual men and gay men since it is becoming increasingly clear that they are shaped and challenged by different experiences, including stressors and support. The findings from this study suggest that diverse groups of bisexual men are at risk for mental health problems due to a number of individual and social factors. These include difficulty both accepting and disclosing their bisexuality, as well as a lack of a sense of social support that could be derived from a community of men who share the same issues. More often than not men described feelings of having to live within “separate worlds” of homosexuality or heterosexuality. Above all, not one participant reported that a bisexual space or community existed. Not only did these men suggest that social space for bisexual men was nonexistent, but their identities were also compartmentalized. How these men saw themselves in any given moment centered on the space they were in, the other individuals they were with, and the norms and expectations associated within these contexts. This division of sexuality, or the lack expression of this sexuality around others, is suggestive of societal pressure to conform to a binary system of sexuality that currently dominates our culture (Angelides, 2001).

The lack of visible community, or space and the limited instances where bisexuality could be expressed to others often led to feelings of sadness or loneliness. Additionally, even for those some men who had not expressed these feelings personally, almost all suggested that as a group bisexual men were especially vulnerable to such social isolation. Family, in particular, may take on an elevated role in the lives of these men because of a lack of community connectedness. Men may invested more into primary bonds with the family since it was difficult to find acceptance or social support in either hetero- or homosexual-dominant communities.

Individual comfort level with bisexuality markedly impacted the degree to which participants felt a sense of belonging within a given space. Similar to other studies, several men expressed feeling uneasy around men they describe as typical “gay” or men who acted feminine (Dodge, Jeffries, et al., 2008). It is unclear whether this was related to negative feelings some men had towards their desire to have sex with other men. However, men who described feeling comfortable in homosexual spaces did not seem to have an aversion to being labeled as “gay.” While some men suggested they felt belonging in gay space because of the connections they made, others reported that fear of physical harm in some heterosexual spaces as a key reason for venturing into gay spaces.

Individual comfort level seemed to have less to do with actual ease within a social space but rather comfort with being associated with homosexual space. Men who indicated lower levels of comfort in these spaces pointed to fear of inadvertent disclosure. Fear of disclosure about sex with men was a predominant concern. However, men also reported distress about not finding acceptance among the gay community because they had sex with both men and women. Men indicated that when in gay space, they often felt like others questioned their “true” sexuality or responded to their claims to bisexuality by saying they were either in denial, and either gay or straight. In other words, while men did not suggest fear of physical violence within gay spaces, they did however point out an inability to integrate into the gay community because their status bisexuality was outright rejected (a sentiment which some equivocated with emotional violence).

The inability of bisexual men to express their sexuality openly within either heterosexual or homosexual spaces presents unique challenges for understanding this population. Where homosexual men have the ability to leave heterosexual space and often find security, belonging, and a sense of self with the gay community, many bisexual men expressed this option as being improbable, if not impossible. While many gay men find personal and social benefits from “coming out,” it is clear that the situation is markedly different for bisexual men, who are most often met with suspicion and scorn.

The results of this study must be considered while acknowledging its limitations. As probability samples of bisexual men are exceedingly difficult to obtain (Jeffries & Dodge, 2007), we relied on purposeful convenience sampling techniques in order to acquire study participants. Working in collaboration with community members who serve the health needs of bisexual men assisted with recruit a diverse sample of bisexual men that was reflective of the wide range of these men in the area under study. However, because probability samples were not feasible, we do not know how well our approach sampled the wide array of existing sub-populations of bisexual men. For example, even though we included a good number of married men and men with children, it is possible these men are even more difficult to reach through the types of methods we employed.

Additionally, although we intentionally recruited a diverse sample in terms of race/ethnicity and other factors, exploring mental health and other related issues in relation to these was beyond the scope of this paper. For example, from some quotes reported here, it may initially appear that, in relation to race/ethnicity, White men were on the whole more “comfortable” with their bisexuality than other men. One might suspect that because of the benefit of White male privilege in society, they do not deal with the stigma of being Black or Latino on top of being bisexual. However, after scratching beneath the surface, White men are also more likely than any other group to be currently married. Marital status seemingly trumped other characteristics such that (apart from a small number of men who engaged in “swinging” and group sex activities with their spouses) the vast majority of married men were most “uncomfortable” in terms of their sexuality. Age also clearly influenced men’s experience of sexuality. On the whole, younger men of all racial/ethnic groups reported experiencing less stress than their older counterparts. It was not our intent to ignore the importance of the intersectionality of these issues in our study participants’ lives; rather, they have been explored in greater depth in other publications by our study team.

CONCLUSIONS

This study provides valuable insight into the everyday lived experiences of these men. Findings suggest that bisexual men do not feel belonging overall in any space and this may make it more difficult for them to express their sexuality to others compared to other men. It appears that a potential solution to the lack of community belongingness would require construction of bisexual spaces, both symbolically and concretely. Additionally, programs emphasizing “self-love” and personal acceptance of bisexuality are clearly warranted given that few bisexual men receive any positive feedback regarding their sexuality on a daily basis. Cumulatively, the stigma and discrimination associated with biphobia have the potential to cause great distress among these men. Community-level empowerment interventions that emphasize self-acceptance, community building, and maximizing social support (for example, the Centers for Disease Control and Prevention’s M-POWERMENT) have shown relative success in increasing positive health behaviors among gay-identified men. Public health researchers and practitioners must also develop ways to work pragmatically and non-judgmentally with bisexual men, as separate and distinct from heterosexual and homosexual men, in order to assist in improving health outcomes in the often underserved population.