From: MShernoff Date: Fri, 27 Mar 1998 16:50:33 EST Subject: gay widowers Gay Widowers: Grieving in Relation to Trauma and Social Supports Michael Shernoff, MSW Published in the Journal of the Gay & Lesbian Medical Association, V.2, No.1, March, 1988 1998 PLENUM Publishing Corporation Permission is granted to copy or reproduce this article either in full or in part, without prior written authorization of the author on the sole condition that the author is credited and notified of reproduction, and that the publisher's copyright, and place of publication appear. Abstract Even though gay men experienced the death of partners before the onset of HIV disease, and the AIDS epidemic has brought increased attention to the plight of gay male widowers, there is very little research on the specifics of how gay widowers mourn and what is required for them to adjust to their bereaved state in an adaptive way. Objective: To describe the psychosocial issues relevant to gay widowers, and how social support is central for them to resolve their grief in a functional way, and to offer some comparisons between heterosexual and gay widowers, thus assisting health care professionals in best serving this population and illuminating areas for further research. Design: The findings are primarily from empirical clinical practice with support from the literature. Results: The lack of recognition for male couples in general and for the status of a gay man as a widower in particular, complicates the grieving process. Conclusions: Gay men whose partners die exhibit the constellation of classic symptoms manifested by survivors of other traumatic events. Mental health professionals can play important roles in providing support and healing during the mourning process of gay widowers. Introduction When a gay man's partner dies, his trauma is often exacerbated by the lack of mainstream culture's recognition of his relationship, his loss, and being a widower. All surviving partners regardless of sexual orientation experience certain psychosocial and intrapsychic reactions. In addition, gay men face unique stressors that complicate bereavement. This article is based on fifteen years of clinical work with gay widowers and addresses their psychosocial issues, the impact that absence of social supports has on their grief and how mental health professionals can help facilitate mourning. AIDS has brought focus to gay widowers. "The bereavement process experienced by gay men who experience losses due to HIV/AIDS must be understood as a chronic state of mourning. The implications of overlapping losses where the onset of mourning for one loss overlaps with the end stage of mourning for another loss are significant. Complicating this chronic state are post traumatic stress, loss saturation, unresolved grief, survivor guilt, and fear of infection with HIV."(1) The experience of many urban gay men is similar to that of a survivor of a major catastrophe, and must be assessed and addressed within this context. Literature Review Most research on grieving spouses focuses on heterosexuals, especially elderly widows and widowers(2, 3, 4, 5, 6,7,8). Research documenting and describing the intimate relationships of gay men began to emerge in the late 1970s,(9, 10, 11, 12,13, 14). McWhirter & Mattison(15) estimated that there are over one million male couples living in the United States, arriving at this figure using a conservative extrapolation from Bell & Weinberg(9); Jay & Young(16) and Spada(17). "In the last decade an extensive literature has evolved about grief, but until very recently, little or no recognition has been given to the grief of homosexual men who survive the death of a partner or friend. Recent theoretical and clinical attention to AIDS and the special problems of homosexual partners of persons with AIDS has resulted in interest in the needs of survivors in relationships that continue to lack social approval"(18). Prior to AIDS there were only two professional articles that specifically addressed bereavement issues of gay individuals (19, 20). With the onset of HIV disease, articles and books pertaining to gay men, grief and mourning began to appear (1, 18, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33). As Martin (22) noted "most current knowledge of bereavement is derived from research on conjugal loss and, to a lesser extent, on the loss of a child or parent. The extent to which these findings generalize to gay men who have lost lovers and close friends is unknown." Thus the mental health needs and responses of gay widowers is largely uncharted territory. Even as the numbers grow, there has not been sufficient research and literature exploring the clinical implications for gay widowers. General Dynamics of Being a Widower For all men, widowerhood needs to be viewed as both a social and intrapsychic phenomenon. Rubinstein described widowerhood as: "a social role, produced by the transition from married status to nonmarried by the death of a spouse. The transition to widowerhood as a purely social role can be painful and awkward, with inadequate role modeling and little direction. Intrapsychically, the adjustment to any loss is extraordinarily painful and stressful"(34). Prior to AIDS few young or middle aged gay men knew any other gay men whose partners had died. Identifying as a gay widower has often been complicated by the absence of visible role models. Bowlby(35) lists three phenomena typical of adults to the loss of a spouse. These are persistence of the tie to the deceased by the survivor, emotional loneliness, and ill health. While Rubinstein and Bowlby only discussed heterosexual men, their observations are equally applicable to gay widowers. Glick et al(36) found that men whose wives died tended to define what happened to them as a dismemberment rather than an abandonment. Gay widowers often speak in terms of having lost a part of themselves after the death of their partner. One man said: "His death felt as if a part of my soul had been amputated." Another told of "feeling as if both of my legs have been cut off and having to learn how to walk again, but only this time with a prosthesis." Rubinstein(34) characterized elderly widowers as either successfully or unsuccessfully reorganizing their lives following the death of their wives. The successful group of men functioned well, appeared happy and had detached themselves from the continued participation in the former marriage. The men unsuccessful at reorganizing their lives admitted various degrees of unhappiness and appeared to be still married, psychologically, even after the passage of years and were unable to reconstruct a full new life. DSM-IV(37) states: "The duration and expression of 'normal' bereavement varies considerably among different cultural groups. The diagnosis of Major Depressive Disorder is generally not given unless the symptoms are still present 2 months after the loss." Heyman & Gianturco(5) found that long term adjustment to bereavement was generally characterized by emotional stability, stable social networks, few life changes and few bereavement-related health deficits. All these constructs are equally relevant to gay widowers. Glick et al(36) found that widowers moved more quickly than widows into dating and eventual remarriage. Some gay widowers begin dating soon after the death of their partner and others do not. All widowers who resumed dating described needing to be able to talk about their deceased partner. "Brad, the first man I dated after Chris' death was not threatened by Chris. Possibly because Chris' death was relatively new, and my grieving process was integrated into the development of our relationship." The issue of comparing the deceased lover with the man being dated frequently arises. "Michael knew that there were times I compared him to John. He also knew that John's death had become a part of who I was." For men who want to partner again, the ability to begin a new relationship is one indication they are working through their grief. Glick et al(36) suggest it is not wise to correlate social recovery from the death of a spouse with remarriage. Yet establishing a new primary love relationship is one indication that the gay widower is reorganizing his life. Issues Specific to Gay Widowers Issues for all widowers include: How long does one remain a widower? What is entailed in developing an identity as a widower? How does a bereaved man go about adjusting in healthy and adaptive ways to the trauma of a partner's death? Does he still consider himself a widower even after falling in love with someone new and moving into a new relationship? Is there any resolution to the enormity of this kind of loss? Issues unique to gay widowers include: How does where he is on the continuum of "coming out" and developing a positive gay identity(38) affect his grieving and ability to ultimately resolve his mourning? Since the onset of AIDS many urban gay men have experienced multiple AIDS-related deaths. How does the death of a partner trigger the grieving process for other deceased friends or loved ones? If the grieving widower is himself HIV-positive, how does his health status further complicate the process of his mourning? If the couple did not draw up the necessary legal documents giving the survivor clear civil and medical power of attorney and an ironclad will, a gay widower may be subjected to indignities and other losses immediately following the death of his partner that a heterosexually married man would not encounter. Some think of being a widower as a transient identity that ends once they feel that their period of acute mourning is over, or they have entered into a new romantic relationship. For others, being a widower becomes integrated into the totality of their personhood which is one example that they have entered a very advanced phase of grieving that Bowlby(39) describes as reorganization, characterized by getting over the loss and building a new life. Helsing, Szklo & Comstock(2) demonstrated that male survivors have a higher rate of mortality after widowerhood than do women. As the following case illustrates, gay men with AIDS, may be at increased risk for dying following the death of a partner, especially if most or all of their friends have predeceased them. Joe and David had been partners since they met as undergraduates, fourteen years earlier. When they began couples therapy they both had been diagnosed with AIDS for three years and each had Kaposi Sarcoma, Cytomeglovirus in their eyes and intestines, and severe weight loss. After a period of slow decline, Joe died in January, 1993 with David at his side. Immediately following Joe's death, David's health, which had always been stable, began to rapidly deteriorate, and he died in June of the same year saying that a broken heart and not AIDS had killed him. Homophobia and Gay Widows "Society offers little opportunity for the overt expression of grief and bereavement in general, and even less opportunity for gay men. Even as gay men grieve, they are subject to homophobia."(18) Sexual orientation has nothing to do with the dynamics of grief, though as the following case illustrates, the ramifications of homophobia can greatly complicate the grieving process of a gay man. Ralph, a thirty nine year old man who sought therapy shortly before the death of Emmanuel, his partner of eight years, described feeling overwhelmed by sadness. He had been confident of his ability to weather this emotional storm until Emmanuel's parents told him that he was not welcome at the funeral and that he would have to move out of the apartment he and Emmanuel had lived in for the past five years since it was owned solely by Emmanuel and there was not a will bequeathing the apartment to Ralph. "Not only have I lost my lover," he told me during one session, "but I am faced with the prospect of being evicted from my home at the same time. This is more than I can bear." The additional stress of being forced to move out of his apartment contributed to Ralph's distress, depression and anxiety following Emmanuel's death. The fact that Ralph was faced with the reality of becoming homeless was for a few weeks of greater urgency than dealing with the death of his beloved partner. One dynamic unique to the surviving partner of a same sex relationship is that his or her relationship is not universally recognized, validated and valued. "The heterosexual widow or widower who loses a mate receives a tacit level of social support and condolence. Gay widowers may be more apt to encounter scorn, ostracism, fear or blame."(40) Thus many gay widowers' mourning is complicated by the fact that theirs is a "disenfranchised grief." Doka(41) explained that disenfranchised grief occurs when 1) the relationship is not recognized, 2) the loss is not recognized, and 3) the griever is not recognized. Not all gay widowers experience disenfranchised grief. When an individual has not hid his sexual orientation he is more likely to have a viable friendship network of supportive individuals who will play a crucial role in his mourning. The widower pretending not to be gay and that his live in lover was "just a room-mate" is infinitely more susceptible to experiencing disenfranchised grief than his peer who has access to sympathy and support at least within the gay community. "All of these factors must be taken into account in redefining the process of grieving and identifying the coping mechanisms and interventions appropriate for responding to the needs of today's gay men."(1) Disenfranchised grief may contribute to keeping the widower's relationship with the deceased active as a defense from having the relationship negated. For some gay men the trauma of losing one's partner has the potential to reawaken previously resolved internalized homophobic feelings that include shame about being gay. One indication that internalized homophobia has combined with disenfranchised grief is the minimizing or devaluing of the relationship by the surviving partner. If heightened levels of homophobia are left unchallenged by the psychotherapist, the widower is at risk of regressing to a less developed stage of gay identity formation.(38) "With their experience of repeated loss, gay survivors often struggle against being identified as blameworthy."(18) When blame is internalized and becomes merged with homophobia some widowers feel they did something to deserve the pain they are in the midst of experiencing. "If I were not gay perhaps then I would not be feeling this way." While true that if the man were not gay he would not have fallen in love with the man who died and who he is now mourning. The problem in this line of thinking is that it merges being gay with the pain which is an indication of internalized homophobia, rather than recognizing that the pain is an appropriate response to having loved and lost the beloved. If a survivor is HIV positive, the concept of being "blameworthy" can complicate his bereavement as he struggles with "Why am I still alive while my spouse died from this disease?" Siegal and Hoefer(19) and Richmond and Ross(33) highlighted problems such as hostility from families and exclusion from the planning of funeral arrangements, or even from the service itself as unique stressors and a focus of distress that a gay man may be forced to face immediately after the death of his partner. It is not unusual for a gay man to be denied the same bereavement leave from his place of business that any heterosexually married individual normally receives. When his performance is less than stellar after returning to work following the death of his lover, the survivor often is not given the same latitude as a heterosexually married man would receive. This can have the effect of reenforcing self doubt or lowered self-esteem that the widower may already be experiencing. Trauma Theory and Gay Widowers Gabriel(42) stated that "people living with AIDS and their survivors are emerging as the newest group of persons experiencing psychological trauma." Green(43) listed exposure to the grotesque, violent/sudden loss of a loved one as an event that is considered trauma-inducing. A common denominator of all psychological trauma according to Herman(44) is "a feeling of intense fear, helplessness, loss of control and threat of annihilation." Among the signs of turmoil Gabriel(42) listed that surviving partners may exhibit are distressing emotional reactions such as anxiety, dread, horror, fear, rage, shame sadness and depression; intrusive imagery of dying; nightmares; flashbacks of images of the stressor; numbing or avoidance of a situation associated with the images; somatic complaints including sleep difficulties; substance abuse; impaired social functioning; interpersonal difficulties; sexual dysfunction, hyper sexuality and difficulty sustaining intimate relationships. Gay widowers who have experienced the death of their partner from any cause can attest to the presence of these elements in varying degrees of intensity in their everyday lives. DSM-IV(37) notes: "As part of their reaction to the loss, some grieving individuals present with symptoms characteristic of a Major Depressive Episode or Post Traumatic Stress Syndrome." DSM also states that the bereaved individual typically regards the depressed mood as normal. Experiencing vivid recall of the traumatic event is one symptom seen in most trauma survivors. All widowers the author has worked with are able to recount in minute detail the actual moment of his partner's death, or the moment of learning of the death of his partner, even many years later. Surviving partners need to be worked with therapeutically in a way that validates the traumatic nature of the loss in order to help them regain emotional equilibrium. Dworkin and Kaufer(1) instructed professionals consulted by gay widowers to remember that bereavement interventions must be gay affirmative in addressing lowered self-esteem, personal identity and questions about body image, and need to address the reestablishment of meaning in one's life. Social Support and Recovery from Grief There is abundant research demonstrating that inadequate support can contribute to the development of a traumatic stress reaction following any life trauma and that a deficit in social support has been associated with poor outcome in bereavement.(45, 46, 47, 48) Vachon et al(49) found that absence of social support was directly related to continued high distress two years after the death of a spouse. Though the above cited researchers' samples were (presumably) exclusively heterosexual, the author's clinical experience supports that their findings can be extrapolated as pertinent for gay widowers. Supporting this assertion is Lennon et al's research(26) documenting that the amount of social support available to a gay man following the death of his partner from AIDS directly correlates to how he recovers from this event. Studies of survivors of non-AIDS related traumatic situations suggest that the response of the larger community, outside of the kinship group, is an important emotional resource for those surviving a traumatic experience.(44, 50, 51) When a widower is a member of a sexual minority denied visibility and social supports his trauma has the potential to be exacerbated. Herman(44) found that community support in the face of a traumatic event can be of enormous assistance in helping repair the injury inflicted by the traumatic event. Many cities now have bereavement programs geared specifically for gay men who have lost a loved one to AIDS. Gay specific bereavement groups also need to be developed for individuals whose partners have died from a cause other than AIDS. Moving Through Grief The predominant theoretical models in the area of grief and loss are stage models. (52, 53) describing several phases of emotional response as mourners attempt to come to terms with the loss of a loved one. Bowlby(35, 39, 54) proposed four phases of mourning, including shock, searching, depression and reorganization and recovery. Wortman et al,(53) researched whether there was any empirical evidence to support a stage theory of recovery from the death of a loved one. They discovered that the available data did not support, and sometimes contradicted, the stage approach. While some people may in fact follow expected patterns, many do not. Most men do not necessarily proceed in their development as widowers in a linear fashion, but often experience aspects of more than one stage simultaneously, and frequently move back and forth between stages. The death of a partner is often the reason why people begin psychotherapy or counseling. Many men find their need to talk about their evolution and pain is more than their friends can tolerate. It is important to note that traditional individual psychotherapy while certainly useful is by no means the only appropriate way that a health care professional can be of assistance to a gay man during the period following the death of his partner. Referring gay widowers to a gay specific bereavement group is another intervention. Psychiatrists, psychologists and social workers have to be prepared to assume a therapeutic role of support and bearing witness while offering faith and hope for a future that is less filled with pain that may need to transcend traditional psychotherapy or counseling. This becomes a therapeutic necessity especially if the widower is the last surviving member of a friendship and/or support group and the therapist is one of very few people with whom the widower shares a history. One understandable characteristic typical to burying one's partner is intense anger(55), whether it be at the unfairness of life, at God, at the cause of death, at the deceased or just being in the unenviable position of having to pick up the pieces and rebuild a life. Recognizing that there are numerous good reasons to be angry, expressing and integrating this rage are essential components of adjusting adaptively to widowerhood. Gay widowers' anger is only fueled by homophobic reactions and insensitivity to their mourning, and needs to be validated by all clinicians who work with them. Conclusion Invariably, each widower ponders am I doing this correctly? Mental health professionals need to remind grieving gay clients that there is no right or wrong way to go about the process of moving on after the death of a partner. The only incorrect thing to do is to try to avoid the painful feelings that must be experienced. In our society there are powerful cultural myths, usually unspoken, about how to mourn "correctly." "These myths touch on many aspects of grieving--how long to mourn, what to feel, what not to feel, how to behave, how not to behave, when to show certain responses, with whom to share your feelings, and so on. Mourners face many implicit directives about how to conduct their grief."(40). The myths pertaining to how to grieve correctly are not always true. Wortman & Cohen-Silver(56) suggested that many of our most basic, unquestioned assumptions about how people cope with loss may not match people's actual experience. Among the assumptions they questioned are: 1)Is depression an inevitable consequence of loss?; 2) Does the absence of depression indicate a pathological response? and 3) Do all significant losses need to be "worked through" in order to be healed? This author's clinical experience confirms that depression is often but not always an inevitable consequence of losing one's partner and that the absence of depression by no means indicates a pathological form of mourning, and that all significant losses do need to be worked through in order to be healed. There is a necessity to resolve, or at the very least, make significant emotional accommodations to a traumatic life event, in order not to be permanently crippled by it. Schwartzberg(40) suggested that in western culture many people follow a similar path in grieving a major loss. The individual responds with depression and pain for a discrete period that can last upwards to a couple of years, and then gradually returns to his previous level of functioning. He notes that a sizable minority do not follow this path. Mental health professionals need to be aware of and remind grieving clients that there are a multiplicity of ways that people mourn the death of a partner. Some people have a very prolonged grief reaction, while others grieve for a very abbreviated time, regaining full momentum of their lives quickly. Reacting differently from the cultural norm, by grieving too long, for example, or too little, needn't mean that a response is unhealthy. "People vary greatly in how they respond to a significant life upheaval; the absence of turmoil may simply reflect another style of 'normal' response."(40) "For most bereaved people, to keep going after the painful life changes caused by death is the most difficult task of all. When a lover dies, the loss plunges the bereaved person into a world where many of his known and habitual structures of daily life disappear into a world more full of confusion, disorganization and anxiety than it was prior to the death of his partner. A new order has to be constructed."(18) Surviving the death of a partner is a potentially devastating emotional experience. 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Cambridge, England: Cambridge University Press, 1993:23-43. 53) Wortman C Cohen-Silver R Kessler R. The meaning of loss and adjustment to bereavement. In:Stroebe, Stroebe & Hansson, editors. Handbook of Bereavement. Cambridge, England: Cambridge University Press, 1993:349-366. 54) Bowlby J. Childhood mourning and its implications for psychiatry. American Journal of Psychiatry 1961;118:481-498. 55) Kubler-Ross E. On Death and Dying. New York: Macmillan. 1969. 56) Wortman C Cohen-Silver R. The myths of coping. Journal of Consulting and Clinical Psychology 1989;57:349-357. Michael Shernoff, MSW is in private practice in Manhattan and is adjunct faculty at Hunter College Graduate School of Social Work. He edited Gay Widowers: Life After the Death of a Partner, 1997: Harrington Park Press. He can be reached via his web site at http://members.aol.com/therapysvc or via e mail at mshernoff@aol.com Key Words: Gay men, homosexual, widowers, grief, mourning, HIV/AIDS.