Grieving Processes for Men

Written By: Dr. Martin Rovers & Rene Vandenberg 

Introduction

There is a lack of integrated studies in the literature that examines the grieving processes for men.  Although the literature seems to be rife with studies that explore “men” and grief, there is a dearth of literature that looks in detail at the grieving processes for men. The goal of this critical review of the literature is to explore how the grieving processes of homosexual and heterosexual men have been examined theoretically and empirically in the literature and to identify ways in which this literature might inform counselors in their work with grieving men. Subsequently, it recognizes the need for further study in this domain, as indicated through the inherent stereotypes and limitations of the material, as well as the realization that no unified model of understanding the impact of sexual orientation in the male grieving process appears to exist.

Grief Defined

  Traditionally, bereavement is defined as the state or fact of being bereaved, meaning, it is understood as a state of deprivation in which the person is contending with the death of a loved one (Babcock Cove, 1980). In bereavement, grief manifests itself as the primary emotional response. Thus, for the purpose of this discussion, grief is understood as a process that is individual in nature, and is comprised of a biological, emotional, spiritual and cognitive experience in the life of the person who has lost someone  or something, like a job, (Moules et al., 2004).

From a biophysiological perspective, grief can alter the bereaved person’s ability to function by impeding upon his or her neuroendocrine functioning, immune system competence and sleep patterns (Hall & Irwin, 2001; Kim & Jacobs, 1993).  Continual neuroendocrine changes can become maladaptive, and have been associated with different forms of psychopathology, such as depression, panic and anxiety disorders (Kim & Jacobs, 1993) that may hinder resolution of the grieving process.  Irwin and Pike (1993) reviewed several studies of immune functioning during bereavement, and determined that persons experiencing the intense, heightened mental anguish that accompanies bereavement experience alterations in the capacity of the immune system to respond optimally.  Moreover, results such as Irwin et al., (1987) have emphasized a strong link between symptoms of depression and anxiety, to the immune system functions most directly associated with bereavement.  Noteworthy, however is the fact that these symptoms of major stress disorders have been linked to these very immune system changes only in men (Evans et al., 1992).

Depression, is implicated in disturbances in sleep late in the initial year of bereavement and, Reynolds et al, (1992) hypothesize that depression may serve as the pathway that connects loss to alterations in sleep and that these bereavement-related sleep disturbances may create a risk factor for the increased mental and physical health morbidity and mortality associated with significant loss (Hall & Irwin, 2001).

Bonanno (2001) describes grief as a long-term experience that can persist for months to several years and is associated with diverse emotions.  According to Bonanno (2001) grief is not a “one-dimensional emotional phenomenon”  (494) but, rather has been linked to various negative emotions such as sorrow, fury, disdain, antagonism, dread and culpability (Bonnano & Keltner, 1997; Bowlby, 1969b), as well as positive emotional experiences such as enjoyment, pleasure and pride (Bonanno & Keltner, 1997; Shuchter & Zisook, 1993).  Bonanno (2001) argues that grief is related to a reflective assessment of this immutable loss and other significant events in his or her life. Lastly, Bonanno (2001) states that grief leads to diverse coping reactions that can be long-term and directed at alleviating the distress produced by the loss, including alterations in social roles, financial circumstances, or within the family (Bonanno & Keltner, 1997; Shuchter & Zisook, 1993).  These responses challenge the bereaved person’s assumptions about his or her existence, while simultaneously setting the foundation for spiritual change (Balk, 1999).

According to Balk’s (1999) study regarding bereavement and spiritual change, reflecting upon the meaning of human existence and changing personal ideas about his or her position in the world are responses to loss that indicate the occurrence of spiritual change. Balk maintains that three conditions must be present in order for these changes

to occur.  First, the circumstance must generate a “psychological imbalance or disequilibrium that resists readily being stabilized” (485), followed by a time for personal contemplation and lastly, the individual’s life must be “forever afterwards colored by the crisis” (485). For Balk (1999) bereavement is more than a means of coping with loss but is also a life crisis that causes enduring pain and endorses growth and the possibility for spiritual change (Balk, 1999).

In a study exploring the relationship between negative cognitions and emotional difficulties following bereavement, Boelen and colleagues (2003) assessed four cognitions: global negative beliefs, cognitions about self-blame, negative cognitions regarding other people’s reactions after the loss, and negative cognitions about one’s personal grief reactions. Global negative beliefs can develop when the loss presents the individual with data that is incongruent with his or her pre-existent personal belief-system and he or she fails to effectively adapt his or her beliefs.  Self-blame cognitions can influence an individual’s ability to adjust to bereavement because the mourner may blame him or herself for failing to prevent the loss, or for having caused it (Boelen et al., 2003).  Negative cognitions regarding the reactions of others, such as family, friends and colleagues, can be linked to symptoms of traumatic grief such as emotional detachment, hyperarousal, resentment and thoughts of despair which may impede the bereaved from engaging in social activities or establishing new relationships with others (Boelen et al., 2003). Finally, the bereaved individual’s negative cognitions regarding his or her personal grief reactions may have adverse effects on the grieving process (Boelen et al., 2003). For instance, levels of depression, shame and guilt have been correlated with beliefs regarding the appropriateness of his or her feelings. Additionally, the desire to hold on to emotional pain  as a mode of maintaining ties to the deceased can intensify grief reactions and hinder resolution and adjustment to the loss (Boelen et al., 2003).

Gender and Grieving

Neil Thompson (1997) articulated that society understood grief as a social construct primarily fashioned by prevailing gender expectations, as opposed to being a normal reaction to loss. It is not that men are discouraged from displaying emotions rather; society encourages them to only express emotions such as rage or delight while participating in sporting events (Thompson, 2001). However, society encourages women to show a wider range of emotions, including mourning, in a larger variety of social contexts because this is seen as a normative response in women (Thompson, 2001). According to Thompson (1997) the manner in which men and women mourn will be dissimilar because of the persuasion of “gender-structured patterns of emotional response” (77). Within this paradigm, grief is comprehended as an “emotion that needs to be understood in the context of mourning, [thus it is] defined as a socially constructed and codified set of expectations as to how a loss should be normatively dealt with” (Thompson, 1997: 76).

Zinner (2000) acknowledges the fact that society has come to view bereavement as an observable phenomenon that may have found its origins in narratives based solely on female experiences with grief. Therefore, according to Zinner (2000), the tools used to study grief may be inherently influenced by attributes that correspond with a “contemporary and relatively feminine-based profile of grieving [that] may also bias the expected view of bereavement” (182). Thus, society is more apt to recognize and acknowledge “conventional style grievers”; men who show their emotional distress, who are willing to accept comfort from others, and who promote a greater expectation regarding the need for communal support as opposed to “masculine style grievers”, who are disinclined to deal emotionally with grief, who resist social and professional assistance, and who promote independence as a sign of strength (Zinner, 2000).

According to Lund (2001) although gender differences exist in grieving, similar challenges such as being alone, feelings of despair and the different psychosocial changes related to bereavement are experienced by both genders. The apparent differences occurred in the intensity in which grieving widows and widowers displayed their emotions such as crying and in carrying out daily activities of life. For men, difficulties with activities of living included shopping, meal preparation, and domestic tasks within the home. Women acknowledged upkeep of the home, maintaining the vehicle and the organization of legal and financial affairs as difficult. However, despite these existing similarities and differences, Lund (2001) acknowledges that grief is an individual process that depends on one’s ability to create strong internalized coping strategies upon which to draw.

A prominent commonality in the literature reviewed was the fact that widowers, in general, tended to experience difficulties carrying on with their responsibilities while at work and within the home, especially in relation to handling free time and fulfilling family responsibilities (Tudiver et al., 1991). In a longitudinal study, Lehman and colleagues (1987) followed bereaved spouses, who had lost a spouse unexpectedly, and were still having difficulty adjusting to life several years later.  In particular, participating in social activities, diminished confidence in their ability to deal with challenges, and extreme difficulty coping with any profound changes at this stage of life were identified.

In another longitudinal study exploring the determinants of adjustment to bereavement in younger widows and widowers Stroebe and Stroebe (1993) identified that widows had more problems establishing new relationships, than their male counterparts.  According to Bonanno and Kaltman (2001), even after a two year period since the death of a male spouse, 58% of widows had difficulties commencing new relationships, while only 37% of widowers experienced this difficulty. Bonanno and Kaltman (2001) also noted that only 3% of the widows, as compared to 12% of widowers had entered into new romantic relationships by two months, after the passing of their spouse. Furthermore, these numbers increased significantly for men (61%), as compared to women (19%) shortly after two years had elapsed since the death of a spouse. Lastly, this study also determined that younger widows, as opposed to older widows, would more frequently opt to engage in a new romantic relationship, than their seniors. For widowers, the decision to engage in a new romantic relationship was more likely correlated with financial circumstances and the degree of education attained (Bonanno & Kaltman, 2001).

Homosexual Men, Heterosexual Men and the Expression of Grief

For the purpose of this discussion, the men who participate in same-sex romantic relationships are termed homosexuals because their affection and sexual orientation is directed to members of the same gender, while men whose affection and sexual orientation is directed to members of the opposite gender are termed heterosexuals (Bohan, 1996).

According to a study on the facial expression of emotions by Bonanno and Keltner, (1997), a discussion regarding gender and grief by Doka (2002), and a study examining attachment and grief by Shear and Shair (2005) there exists little, if any concrete empirical evidence that supports the notion that widowers must express their emotions in order to have successfully processed their grief. Furthermore, with respect to loss, Doka (2002) identified an important similarity that occurs when either a homosexual or heterosexual man loses a partner.  Doka identified that the bereaved in either population can experience similar challenges and losses that accompany the death of a loved one. What appears to be of essence to these experiences, according to Doka and Martin, is the manner in which each population adjusts internally and, or externally to their grief (Martin, 2002) regardless of sexual orientation.

According to a review of the literature on gender and grief by Doka and Martin (2001), men have difficulty expressing emotion, other than anger, upon the loss of a life partner. As such, Doka and Martin (2001) claim that the basis of this tension arises from the cultural norms that preside over how people are to express their emotions.  Furthermore, according to Walter (2003), expressing emotions such as dread or weeping clashes with the image of masculinity that society upholds, thereby threatening society’s construct of men being viewed as autonomous and in charge. However, despite this assumption, Walter (2003) acknowledges that men have several different manners of expressing their grief. According to Walter (2003), a number of men are able to express their emotions by talking about their pain with family and peers, which she views as a feminine means of communicating emotion. As such, Walter (2003) defines this manner of grieving as a style wherein the bereaved might seek out cherished peers or family members so as to articulate his emotions, by speaking about the history of the relationship while connecting with related emotions.

Additionally, according to Walter (2003), other men may opt not to disclose their emotions regarding grief because they may feel insecure about revealing these emotions. Thus, for this studied group of men, choosing to express their grief may occur through action rather than communication. Walter (2003) claims that these men attempt to heal themselves by altering the future as opposed to revisiting their past. Walter (2003) states that for this particular segment of the male population, responding to loss by expressing grief in a physical manner that involves action and results in concrete outcomes, such as establishing a charity or commemorative for their deceased partner, serves as a means of contending with their loss. Walter (2003) also acknowledges that a third subset of the male population expresses their grief in a cognitive manner, meaning that they seek to determine a rationalization or develop a plan in an effort to assist them to contend with the loss using  a solution-focused approach to loss by naming the dilemma, examining it and then constructing an approach that will allow them to initiate action.

However, Doka (2002) recognizes that certain challenges impact, homosexual men’s grieving processes such as the failure of heterosexual society to acknowledge the legitimacy of the relationship, or its failure to either recognize the bereaved person or the loss.  These issues can further complicate their ability to express their emotions by diminishing their experiences and fostering segregation. Moreover, because contemporary society has failed to legitimize the loss, the bereaved homosexual partner’s suffering may be intensified because instead of being validated, he may be blamed, scorned, ostracized or feared (Schwartzberg, 1996). However, Walter (2003) notes that if a homosexual male has previously revealed his orientation then chances are probable that he will have a support system consisting of friends, from within the gay community, to help him grieve the loss.  As such, homosexual men tend to rely on a “family of choice” according to Martin and Dean (1993: 319) as opposed to their biological family for both emotional needs and tangible support. According to Walter (2003) it is when a homosexual man has not disclosed his orientation by maintaining that his partner was just a roommate that the bereaved male is more likely to be discounted by society.

Furthermore, Walter (2003) suggests that internalized homophobia, meaning “the hatred or denigration of homosexuality that has been internalized by LGB[T] persons themselves” (Bohan, 1996: xiv), may surface through shame resulting in the bereaved homosexual male discounting the value of the relationship while contending with previously (un)resolved concerns around “coming out.” Additionally, if the bereaved homosexual male himself has been diagnosed with HIV, then he may have to contend with his own concerns regarding internalized homophobia, especially as it relates to society more readily identifying him as a homosexual male, and with respect to identifying himself as a person stricken with HIV/AIDS (Cadwell, 1998).

Although guilt is understood to be a common reaction to loss for both heterosexual and homosexual men (Worden, 1991), the presence of guilt, as it relates to loss and AIDS, may further complicate the bereaved homosexual male’s ability to express emotion because he may feel guilty for having survived the loss of the partner (Walter, 2003). Moreover, the bereaved homosexual male may attempt to blame himself for the loss as a means of denying or coping with the deep hurt that accompanies it, especially if the partner is young and is encountering loss for the first time (Walter, 2003). In addition, Walter (2003) acknowledges that bereaved homosexual men who have experienced an AIDS-related death must not only grieve the loss of their partner, but must also contend with the potential loss of their own wellbeing and perhaps, mortality. Thus, the fear of having contracted HIV/AIDS through exposure to the deceased partner adds additional emotional pressure that manifests itself in anticipatory grief (Sherr, 1995), referring to the fact that the bereaved not only grieves the previously mentioned, but also grieves the losses that occur in the present and those that are associated with the future (Rando, 1988).  For the bereaved homosexual man, present losses can consist of the denial of grief, the loss of physical comfort in the form of touch and proximity from peers who once previously provided support by listening, due to the “pervasive fear that getting close to their grief and feelings is equivalent to getting close to the disease” (Biller & Rice, 1990: 289). Future fears often revolve around the loss of the opportunity to reminisce about the relationship due to the trepidation of possibly having contracted the disease from the deceased partner (Biller & Rice, 1990).

Lastly, if the homosexual man is contending with anticipatory grief and has encountered multiple losses throughout his life, in relation to HIV/AIDS, the possibility of increased substance use as a means of coping with emotions such as anxiety and depression is high (Martin, 1988). However, this is a phenomenon that is not strictly applicable to the homosexual population. Other populations, specifically heterosexual men use substances as a means of coping, but while heterosexual men frequently exploit alcohol and tobacco (Clayton, 1979; Blankfield, 1983), homosexual men tend to use barbiturates, amphetamines and cocaine (Sherr, 1995).  For homosexual men then, the death of a partner ( Mayne et al.,1998), and cumulative losses over a brief span of time without having had the opportunity to grieve each (Klein, 1994, in Sikkema et al., 2004) can result in susceptibility to adverse mental health outcomes (Ickovics et al., 1998) and might contribute to an increased risk of engaging in high risk sexual behavior (Mayne et al., 1998) as a means of coping with emotions. However, it must also be stated that bereaved homosexual men, specifically those who possess AIDS-related fears regarding their own vulnerability, will seek out professional resources such as psychological or medical services more frequently than bereaved homosexual men who are not fearing for their mortality (Martin, 1988). Thus, although there are similarities between how homosexual and heterosexual men express their emotions, unlike heterosexual men’s expression of grief, homosexual men’s ability to express their grief is further compounded by these problems, especially if they are related to AIDS-related loss (Walter, 2003).

Limitations

Despite the presence of the previously identified links regarding homosexual and heterosexual men and grief, several important limitations were noted in this literature.  Studies examining bereavement and loss in homosexual men focused primarily on AIDS-related grief (Sikkema et al., 1995; Folkman, 1997; Richards, Acree & Folkman, 1999; Sikkema et al., 2000; & Bonanno et al., 2005). The literature reviewed yielded but two articles examining homosexual men’s grieving within the context of other forms of death such as suicide (Heeringen & Vincke, 2000) and cancer (Tang et al., 2004).  Furthermore, the available literature reviewed creates the false assumption that homosexual men die only of AIDS or of AIDS-related complications, therefore bypassing other forms of mortality. Although in the early 1980s and 1990s, AIDS may have, tragically, claimed the life of a significant number of homosexual men, approximately 467,910 as of 2003 (Sikkema et al., 2004), the fact that the emphasis of bereavement studies has shifted in this direction leaves a significant gap in understanding homosexual men’s grief processes within other dimensions of loss and death. According to Walter (2003), before the occurrence of the AIDS epidemic, only two articles regarding grief and homosexual men had been written.

One sole identified study using a comparative analysis of grief in heterosexual persons as compared to homosexual men again focused on HIV/AIDS losses (Klein & Flecther, 1986).  The researchers concluded that both family members and friends of a person who has died from AIDS will have to contend with complex ramifications, but that the bereaved homosexual partner will have to cope with problems that may result in the disclosure of his sexual orientation, thus incurring social stigma. Furthermore in a study on responses to AIDS-related deaths, Richmond and Ross (1985) identified four important factors that weigh heavily on homosexual men specifically, making it difficult to assign a common understanding of how men grieve to each population; social support, denial of the nature of the loss or of one’s sexual orientation, HIV/AIDS-related self-euthanasia, and bereavement overload. Lastly, in a study that attempted to predict depressed mood in bereaved gay men, Folkman et al., (1996) also acknowledge that factors such as being HIV+ and experiencing losses contribute to differentiating between homosexual and heterosexual caregivers, thus complicating the possibility for generalizations between each population.

Another identifiable limitation of the studies on homosexual men, was the fact that none of the studies reviewed sought to compare homosexual men to a heterosexual male group. Although two studies regarding homosexual men and grief, namely, Richmond and Ross’ study (1985) and Folkman’s study (1996) described differences between heterosexual and homosexual men, neither appeared to use an actual heterosexual male group in which to note potential similarities or differences. The prevailing assumption is that studies regarding heterosexual men and grief either purposely ignore homosexual men or fail to identify them as part of the population studied by simply generalizing findings without clarifying sexual orientation.

With the exception of the Folkman study (1996) and Lennon’s study regarding the influence of social support on AIDS-related grief reaction among gay men (Lennon et al., 1990), the studies reviewed emphasized gay men who were HIV seropositive as opposed to gay men who were HIV seronegative. Research such as Sikkema’s group intervention model for improved coping with AIDS related bereavement (Sikkema et al., 1995) and Weiss and Richards’ scale for predicting quality of recovery following the death of a partner (Weiss and Richards, 1997) failed to clearly identify whether the partners of the bereaved that were targeted in the study were heterosexual or homosexual.

A final and major limitation regarding the comparison of these studies is the fact that the studies regarding heterosexual men and grief were analyzed against studies of women and grief, as opposed to homosexual men. Studies such as Hyrkas, Kaunonen, and Paunonen’s (1997) recovering from the death of a spouse compared the grief responses of men and women within a given time-frame in order to determine how each group reacted to loss. Other studies regarding grief, such as Bonanno et al., (2002), Davis and Nolan-Hoeksema (2001) and Copp (1997) categorized men and women as participants within a study, but did not appear to compare the similarities or differences between each group. Rather, there was an assumption of heterosexuality and the experience of the grieving homosexual men was not assessed.

In sum, it is important to note that the direction of the literature regarding grief and homosexual men has been heavily influenced by the AIDS epidemic of the 1980s (Walter, 2003). As such, it would appear that the tremendous outpouring of literature regarding this global travesty has all but superseded grief in relation to other types of death that homosexual men may encounter. Despite an obvious need to tend to such a devastating crisis, the emphasis of the literature ignores grief in relation to other forms of death thus, inadvertently, perpetuating the stereotypes of homosexual men and AIDS.

Furthermore, in his study regarding psychological consequences of homosexual men in relation to AIDS-related bereavement, Martin (1988) makes an important distinction regarding the generalization of findings between bereavement related studies amongst heterosexual and homosexual men, namely with respect to context. Because of the following factors; including the fact that contemporary studies of death result from previous studies based on spousal loss and to some degree, loss of a parent or child, the fact that homosexual relationships are not legally sanctioned, across the globe, are different from heterosexual relations in a biological manner, and considering the unique characteristics of the AIDS epidemic, the degree in which these findings can be generalized to homosexual men is undetermined (Martin, 1988). In of itself, this important acknowledgment justifies the need for a cross-over study between both populations.

The Role of Sociodemographic Factors upon Grief

The identified rift regarding the lack of cross-over studies between heterosexual and homosexual men may in fact be amplified by existing social pressures that limit each group’s ability to grieve in a similar manner. Furthermore, because of the nature of these pressures and how they impact upon each group, a greater divide arises making it much more difficult to understand the similarities that exist with respect to how each group mourns. The purpose of this section is to examine how sociodemographic factors impact upon the manifestation of grief as experienced by both homosexual and heterosexual men.

In the literature regarding heterosexual men, emphasis was placed on the notion that persons acquire their manner of grieving in accordance to their socialization and membership within a specific cultural group (Hyrkas, Kaunonen, & Paunonen, 1997). As such, what is acceptable with respect to grief is determined by a person’s society, specifically his or her culture (Stroebe et al., 1993). Furthermore, according to Neil Thompson (1997), emotions are developed according to gender, meaning that at a young age, boys are taught to express limited emotions, such as aggression and delight while competing in sporting events, while girls are taught to express a wider range of emotions, including grief, publicly.  Lund (2001) validates this research by acknowledging that the socialization process into the male role means learning to manage his emotions. Lund states that it is not that men are discouraged to express all emotions, but rather, only certain ones (2001) such as grief. According to this socialization process, this means that expressing one’s grief is seen as unmanly. Adherence to this societal expectation pushes men to adopt active coping styles to contend with grief, as opposed to expressing their emotions in an open manner. Active coping styles such as immersing one’s self into his work, may be adopted to suppress the emotions related to grief, for fear that society may

view the man as weak. This might mean taking on several large projects at once in an effort to burn time, energy and attention that would otherwise be directed to grief. Furthermore, risk-taking behaviors such as drinking and driving or engaging in unprotected sex with several partners can serve as a cover for expressing grief (Staudacher, 1991) while simultaneously fulfilling gender-assigned roles and beliefs regarding manhood. Thus, society encourages men to deal with grief by immersing themselves into their work or by getting involved in recreational or sports activities (Staudacher, 1991) as opposed to contending with the reality of their grief. As such, the expression of grief may be expressed in a more intense and aggressive caliber of play during these sporting activities, as opposed to shedding tears with friends.

For heterosexual men, the perceived fear of homophobia, meaning that he possesses an irrational fear of homosexuality (Bohan, 1996) further complicates a man’s ability to express grief, by barring him from reaching out to other men. Based on the negative impact of this sociodemographic factor, the man’s reaction to grief might be to withdraw socially from others, thus, isolating him from peers, especially males for fear of being seen as vulnerable. Furthermore, given that various researchers have identified that emotions are developed in relation to gender, openly displaying grief may result in derogatory comments about one’s masculinity, thereby causing the man to further lose interest in his social network (Thompson, 1997; Lund, 2001). Thus, dealing with grief becomes a solitary activity whereby the man contends with his grief in a private manner for fear of being labeled as unmanly or as a homosexual (Staudacher, 1991). However, it must also be articulated that this is not a universal for all men. Some men’s coping style, be they heterosexual or homosexual, is to adopt a masculine style of coping (Zinner, 2000), which means that rejecting the help of others is normative.

Unfortunately, even this style of grieving comes under the scrutiny of society because men whose style is to mourn in this manner are subjected to other forms of sociodemographic pressures. Because some men; heterosexual or homosexual, refuse assistance from others, they are thought of as putting on a display of strength, that is bolstered by “cultural values that encourage stoicism and a stiff-upper lip mentality consistent with a strong male image” (Zinner, 2000; 185). Given that society adheres to these kinds of dysfunctional values, these men are forsaken because their grief is not visibly manifested.

For homosexual men, the literature states that societal pressures impact upon their grief experiences in many ways, such as through the lack of social support, denial of the nature of the loss or of one’s sexual orientation, being HIV positive, and the denial to participate in funeral preparations (Biller and Rice, 1990; Giulino, 1998; Doka, 2002). Furthermore, many of the sociodemographic pressures that apply to heterosexual men are also applicable to homosexual men. However, these stresses are compounded upon due to the additional forms of stigmatization that society casts towards homosexual men as mentioned above. With respect to the previous factors, Meyer (2003) identified the concept of social stress as an important sociodemographic factor that has a detrimental impact upon the lives of people identified as belonging to stigmatized social groups such as the LGBT community.

Based on the concept of social stress, Meyer (2003) further identifies the concept of minority stress, as the surplus of stress that individuals from stigmatized social categories experience on a daily basis due to their social, often minority, status. For some homosexual men these forms of social stress impact upon their ability to demonstrate grief by causing shame about their identity to surface (Walter, 2003). As such, previously dormant feelings regarding internalized homophobia can be reawakened. According to Meyer and Dean (1998) internalized homophobia is experienced as “the gay person’s direction of negative social attitudes towards the self, leading to devaluation of the self and resultant internal conflicts and poor self-regard.” For Meyer (2003) the continued impact of negative stress factors can develop into mental health problems, such as depression, substance abuse, anxiety and suicidal ideation, especially for gay men who have concealed their sexual orientation.

Furthermore, according to Doka (1989) these men are susceptible to the ramifications of disenfranchised grief, referring to “the grief that persons experience when they incur a loss that is or cannot be openly acknowledged, publicly mourned, or socially supported” (4). As such, the bereaved homosexual man, having lost his partner, is not recognized by society as a legitimate mourner. Therefore, according to Walter (2003: 87), feelings normally associated with grief such as “anger, guilt, sadness, depression, loneliness, hopelessness, and numbness,” can be intensified, due to the fact that the relationship was never recognized, the bereaved partner’s loss was not acknowledged and the griever was excluded from the funeral proceedings. All of these sociodemographic stressors culminate in the perceived stereotype that the homosexual man does not need to grieve, thus social recognition of his need to grieve is all but unacknowledged. Therefore, isolation becomes the acceptable forum in which to grieve, especially for the homosexual man who has never revealed his sexual orientation (Walter, 2003).

According to a study by Biller and Rice (1990) the bereavement process of gay men was aggravated by stigmatization directed at being a homosexual and towards the issue of AIDS/HIV. Richmond and Ross (1995), reported that death resulting from AIDS complicated the manner in which the bereaved homosexual man grieved by adding extra stressors to his process. These concerns involved issues regarding the source of infection,

caring for the person who was sicker, changes to the quality of the relationship and recognizing the fact that they might also experience a similar death. Biller and Rice (1990) also identified factors such as grief resulting from multiple deaths, deficiency in support from immediate family, exclusion from participating in the preparation of funeral provisions, and the refusal to recognize the bond between the bereaved and the departed. Each of these sociodemographic stressors contributes to the failure to recognize the status of the relationship thereby diminishing the surviving partner’s grief.

In their 1986 research project examining psychosocial stressors of being in a relationship with a person who has AIDS, Geis, Fuller and Rush (1986) determined that social stigma also manifested itself through the rejection of friends, that was especially evident through these friends’ refusal to socialize with the participants. Participants also identified that stigma emanated from various religious affiliations that coupled AIDS with eternal punishment. According to the study, all 26 of the participants found this form of stigmatization to be extremely hurtful and isolating (Sherr, 1995). Finally, Geis, Fuller and Rush (1986) identified that a sense of fervent irreverence towards the medical community existed with respect to the insensitivity of the emotions of the participants as evidenced through some doctors’ responses towards these persons. Each of these factors contributes to undermining a sense of closure for the bereaved gay man because they potentially prolong and intensify his grief by refusing to legitimize his suffering.

Doka (1989) discussed the experience of disenfranchised grief growing from a relationship not being legally recognized such that same-sex partners may be deprived of any identifiable role or occasion to openly mourn and commemorate their love because society did not acknowledge them to be spouses.  Furthermore, many of the forms of stigma that were previously mentioned such as the failure to recognize the relationship, refusal to acknowledge the loss, exclusion of the bereaved either by being displaced from the home that the couple shared previous to a partner’s death or segregation from funeral preparations, and the circumstances surrounding the death, such as AIDS, are all manifestations of this social phenomenon and contribute to the overall experience of loss and which must be considered when attempting to facilitate healing in homosexual men dealing with the loss of a partner.

Clinical Implications of review

            In the same way as all grieving individuals may need assistance in dealing with a major loss in their lives, homosexual men are not alone in the need for support around the biological, emotional, cognitive and spiritual issues identified earlier in this review.  In particular, self care, attention to stress and relaxation along with the cultivation of healthy coping skills including diet and exercise will assist a gay man in dealing with some of the biological impact of grieving that all men may experience.  In terms of the potential cognitive changes; a homosexual man may require assistance in dealing with the  global negative beliefs identified by Boelen and colleagues (2003) that may be experienced by any grieving man with particular attention to how being a member of a sexual minority may exacerbate the potential for self-blame, other people’s reactions after the loss, and negative cognitions about one’s own response to grief within a culture that may not validate the aggrieved person’s relationship and experience of loss.

Counsellors need to be aware of the potential to assume that the loss is necessarily related to AIDS/HIV when assisting the individual to process his loss. Of particular importance to assisting a homosexual man struggling with processing a major loss is the need to address the impact of sociodemographic factors on the capacity of the man to openly grieve.  In particular, the open expression of emotion and seeking social support may be difficult for a man already feeling marginalized and stigmatized.

Conclusion

Given that the literature appears to support the notion that the cultural milieu stigmatizes the grieving process of both heterosexual and homosexual men, in that society assigns expectations on how, with whom, where and when men in general are to express grief, these expectations might diminish the genuine acknowledgement and expression of grief that men in either population are encountering. An important distinction between both populations is that the stigma that society casts upon the bereaved homosexual man is not simply AIDS-related. Rather, according to Siegal and Hoefer (1981) in their pre-AIDS epidemic article regarding bereavement and counseling for homosexual men, the failure of society to recognize and sanction same-sex relationships, as well as to cast stigmas upon the bereaved homosexual man is a concern that has been identified as early as 1963 in Goffman’s work. Furthermore, whether or not their grief is even validated by society appears to depend on whether society itself acknowledges the couple as a legally sanctioned and recognized relationship, identifies the loss as valid, and accepts the surviving partner as the legitimate partner of the deceased, be it in a heterosexual or homosexual relationship (Doka, 2002).

Moreover, exploring grief in relation to other forms of mortality with respect to homosexual men has become difficult since the occurrence of the AIDS epidemic in the early 1980s.  As previously identified by Walter (2003), until the AIDS epidemic occurred, only two articles regarding grief in relation to homosexual men and death had been written. With respect to this study, the literature review only yielded two non AIDS-related articles; one regarding suicide (Heeringen & Vincke, 2000) and another discussing cancer (Tang et al., 2004). In addition to the above, the literature review produced only one article, Klein and Fletcher’s 1986 study, that identified the grieving processes of homosexual men, but emphasized their experience by comparing them to heterosexual men and women, as opposed to an exclusively heterosexual male population. Thus, these facts appear to indicate that a significant gap exists regarding the lack of accessible cross-over studies between both groups. Although the literature review produced sufficient data to support the notion that stigma and social stressors do impact upon the grieving experiences of men, the findings were not derived from cross-over studies between heterosexual and homosexual men. Thus, the research reviewed did not appear to address the need for a unified model of understanding regarding the impact of sexual orientation on the male grieving process. As previously stated this might be an oversight of the research, in that the researchers potentially assume that the male grieving process is the same for each population, or that a bias exists with respect to inclusiveness, meaning that homosexual men are purposely excluded. Given these concerns, the primary question that arises from this literature review is why has the research so far failed to address this avenue of research? It is clear from this literature review that there is a need for research in this area, and research aimed at developing a unified model of the impact of sexual orientation on the grieving process in men is needed to correct this absence in the literature.

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