The Importance of Social Support, Positive Identity, and Resilience in the Successful Aging of Older Sexual Minority Men

The aim of this study was to assess the relationship between social support, positive identity, and resilience and the successful aging of older sexual minority men. The study involved having 210 self-identified gay and bisexual men aged between 50 and 80 years complete a cross-sectional online survey comprised of sociodemographic information; the Portuguese version of the Multidimensional Scale of Perceived Social Support; the Lesbian, Gay, and multifactor Bisexual Positive Identity Measure; the Connor–Davidson Resilience Scale 10; and the Successful Aging Perceptions Scale. The results showed that self-identified gay participants showed higher levels of positive identity, while bisexual participants scored higher for resilience, mental health, and successful aging. Higher levels of social support, resilience, and positive identity were significant predictors of mental health (28%), physical health (18%), and successful aging (10%) in our sample. These results offer similarities with the growing body of literature on the positive factors of successful aging in the gay and bisexual men communities, which is an important step in the development of aging and health preventive initiatives among this population.


Introduction
Gay and bisexual men often experience extensive psychosocial vulnerabilities, mainly due to exposure to social stigma [1,2], and thus become more likely to develop physical and mental health problems and greater psychological distress and loneliness, in addition to financial, social, and professional vulnerabilities [3][4][5]. According to the minority stress theory [6,7], these experiences are directly related to long-term discrimination and stigmatization that are present in an oppressive environment, characterized by heteronormativity.
For older sexual minority men (OSMM), in addition to stigma associated with their sexual orientation status, they also face stigma associated with aging related to changes in physical functioning and social roles, since older individuals are seen as no longer contributing to the development of society; this creates increased feelings of loneliness, helplessness, devaluation, and low self-esteem [8][9][10]. Ultimately, this double stigma will impair their successful aging [11,12].
It is also important to recall that OSMM grew up at a time when homosexuality and bisexuality were severely criminalized and considered mental health disorders [13,14]. Before 1973, the American Psychiatric Association classified homosexuality as a sociopathic personality disorder [15,16]. As a direct effect of this oppressive environment, many OSMM had to hide their sexual identity or lead a concealed life, living in constant fear of rejection or persecution [17,18], which is associated with worse health outcomes and unsuccessful aging [14,15]. with successful aging among OSMM. This information is fundamental for the construction of effective measures to support positive aging in this population in Portugal.

Participants
A group of 210 men between 50 and 80 years of age participated in this study (mean age = 60.03; SD = 6.33). Of the participants, 85.3% identified as gay and 14.7% as bisexual. The majority claimed to be employed (68.7%), possess a university education (68.6%), and be of middle socioeconomic status (68.7%). Regarding family status, 51.7% said they were single, 51.2% lived alone, and 68.7% had no children. Table 1 presents the sample's sociodemographic characteristics in further detail.

Measurement Instruments
The study collected sociodemographic information using a questionnaire that asked participants about their age, sexual orientation, profession, socioeconomic status, educational level, marital status, living situation, and if they had children.
The study also utilized the Portuguese version of the Multidimensional Scale of Perceived Social Support, or MSPSS [48], to measure participants' social support, which was originally developed by Zimet et al. [49] and is one of the most extensively used instruments to assess social support. It assesses subjective perceptions of social support by collecting perceived adequacy of social support from three sources: family (e.g., "I can talk about my problems with my family"), friends (e.g., "I have friends with whom I can share my joys and sorrows"), and significant others (e.g., "There is a special person in my life who cares about my feelings"). It is a Likert-type self-response scale, with 12 items and 7 response categories with a response scale between 1 (completely disagree) and 7 (completely agree). In the current sample, Cronbach's α for the scale was 0.95, demonstrating excellent internal reliability.
The multifactor Lesbian, Gay, and Bisexual Positive Identity Measure (LGB-PIM) [31], adapted to Portuguese, was used to measure positive identity, which consists of 25 items and is composed of five dimensions: self-awareness (e.g., "My LGBT identity motivates me to be more self-aware"), authenticity (e.g., "I embrace my LGBT identity"), community (e.g., "I feel included in the LGBT community"), intimacy (e.g., "My LGBT identity allows me to understand my sexual partner better"), and social justice (e.g., "I am more sensitive to prejudice and discrimination against others because of my LGBT identity"). Respondents rated each item on a seven-point scale ranging from 1 (strongly disagree) to 7 (strongly agree). An average score was calculated for all items, where a higher score indicated greater positive identity. In the current sample, Cronbach's α for the LGB-PIM was 0.92, demonstrating excellent internal reliability.
This study measured participants' resilience using the Connor-Davidson Resilience Scale 10 (CDRISC-10) [50], which consists of 10 items assessed using a Likert scale ranging from 1 to 5 points. The CDRISC-10 asks subjects to evaluate statements and the extent to which they applied to the subjects' lives over the past month (e.g., "Under pressure I stay focused" or "I think of myself as a strong person when facing challenges"). Resilience levels were evaluated based on the total sum of all items of this self-response scale, with higher scores reflecting higher levels of resilience. As in the Portuguese validation study [51], in the current sample, the Cronbach's α for the CDRISC-10 was 0.93, demonstrating excellent internal reliability.
Finally, this study measured participants' successful aging perceptions using the Portuguese version of the Successful Aging Perceptions Scale (SAPS) [52]. Respondents were asked to rate how important (ranging from 1 = not at all important to 5 = very important) they thought of 12 successful elements of aging (being independent, having friends, living with children or other adult family members, financial security, having physical mobility, being free of chronic diseases, being able to work, being cared for by children or other family members, having an active social life, living with a partner, being able to take care of family members, and being happy). In the current sample, Cronbach's α for the SAPS was 0.86, demonstrating very good internal reliability. In addition to responding to the SAPS, participants were asked to respond to questions concerning the self-assessment of their physical and mental health, using a Likert-type response scale ranging from 1 (very poor) to 5 (excellent). Participants responded to the following questions: "In general, would you say your physical health is . . . " and "In general, would you say your mental health is . . . ".

Procedures
This study created a website that included the measurement instruments, which was later disseminated through the Internet. The researchers specifically created this website for the purposes of this study, and participants were invited to voluntarily partake in the study through a message containing a link to the website. Sample recruitment was conducted among gay and bisexual men over 50 years of age, using social networks, LGBT organizations, mailing lists, and electronic notifications. Although most developed world countries characterize old age starting at 60 years and above, we included middle-aged men (>50) in the sample because this stage of life is distinctive in both the quantity of stressors experienced and their nature, and we wanted to capture men's ageing complexities in relation to midlife as the aging cycle begins at this phase. The study recruitment message directed participants to the website, which explained the study objectives, the anonymous and confidential nature of its personal data collection, informed consent, and a guarantee that the data collected would be used solely for statistical purposes, in accordance with the Declaration of Helsinki concerning the ethical principles for research involving human subjects. Ethical approval was granted by the Ethics Committee of the University of Beira Interior (code number CEUBI-Pj-2020-088). Table 2 shows the results for participants' levels of social support, positive identity, resilience, physical and mental health, and successful aging by sexual orientation. Participants' general mental health perceptions were also relatively high, as shown by an average score of 4.18 (SD = 0.93) on the general mental functioning self-assessment. The sample demonstrated moderate scores for all variables, but when analyzing differences by sexual orientation (gay and bisexual), the following results showed statistically significant differences (p < 0.05): positive identity (t (208) = 3.104; p = 0.002), indicating that gay participants scored higher; resilience (t (207) = −2.515; p = 0.013), indicating that bisexual participants scored higher; mental health self-assessment (t (207) = −2.250; p = 0.029), indicating that bisexual participants scored higher; and successful aging (t (208) = −1.948; p = 0.048), indicating that bisexual participants scored higher (see Table 2). Sample size discrepancy (gay participants = 179 vs. bisexual participants = 31) may be attributable to the fact that bisexual older men are far less likely than older gay men to be "out", and, therefore, are more invisible and harder to reach. A correlation matrix was created using all variables to assess the levels of association among social support, positive identity, resilience, mental and physical health, and successful aging perception variables. As displayed in Table 3, significant correlations were found between mental health self-assessment and social support (r = 0.391; p < 0.001), positive identity (r = 0.286; p < 0.05), and resilience (r = 0.475; p < 0.001); physical health self-assessment and social support (r = 0.330; p < 0.001), resilience (r = 0.347; p < 0.001), and mental health (r = 0.393; p < 0.001); and successful aging and social support (r = 0.308; p < 0.001), and physical health self-assessment (r = 0.179; p < 0.001).  Finally, three multiple linear regressions were performed to determine the predictive effect of social support, positive identity, and resilience on successful aging perceptions, mental health, and physical health. The following assumptions were met: linearity (the relationship between independent variables and the mean of dependent variable was linear), homoscedasticity (the variance of residual was the same for any value of any independent variable), independence (observations were independent of each other), and normality (for any fixed value of any independent variable, the dependent was normally distributed. To measure multicollinearity, we used the variance inflation factor (VIF = 1), which indicated that the variables were not correlated. As shown in Table 4, all models obtained were significant, indicating that social support, positive identity, and resilience explains 10% of successful aging perceptions (social support being the most significant predictor), 28% of mental health (social support and resilience being the most significant predictors), and 18% of physical health (social support, positive identity, and resilience all being significant predictors).

Discussion
The main purpose of this research was to assess the relationship between social support, positive identity, and resilience and the successful aging of older gay and bisexual men in Portugal. Our results corroborate other research that aims to address the positive aspects of aging among LGBT people [11,15]. In fact, approaches that focus on the risks for the older LGBT population can lead them to be portrayed as pathological victims, while positive qualities developed by this population, such as building resilience and crisis competence, can go unnoticed [53].
Our results may then be associated with the skills and competencies that these men have learned to deal with the challenges and adversities imposed as a gay or a bisexual man throughout their lives in the context of a heteronormative society that classified them as inappropriate and illegal [14,18]. As a result, older gay and bisexual men have developed coping skills that prepared them to also deal with the specificities of aging, contributing to a better experience of this period of their lives [54,55] compared to their heterosexual peers [39,53].
Gay men showed the greatest positive identity scores. These results were expected to the extent that bisexual men tend to experience greater discrimination and biphobia, both by heterosexual and gay individuals who often point out that these people do not come out as gay [11,56,57]. These attitudes influence a higher level of internalized homonegativity, resulting in less acceptance of their bi identity [58]. Higher levels of positive identity in gay people have been previously highlighted in comparison to their bisexual peers [59][60][61][62][63].
On the other hand, higher levels of resilience, mental health, and successful aging were noted in the bisexual men in the sample. These results may be related to greater learning and crisis resolution skills that these men may have developed because they live in scenarios and contexts of adversity throughout their lives regarding their double stigma exposure [55,58,64] and its possibility of multiple relational experience [65][66][67][68]. In addition, higher levels of resilience [19,69] and positive mental health functioning [19,38] can enhance successful aging among older self-identified bisexual Portuguese men.
For social support and physical health, there were no significant differences between sexual orientations, being moderately above average for the entire sample. Although these results are positive, they contradict most studies that suggest bisexual people have a greater social support network [38], since bisexual men are more likely to have had opposite-sex marital relationships and may also have children [68,70]. In contrast, older gay men tend to have higher rates of loneliness and lack of contact with friends and the LGBT community [43,44], which has already been associated with poorer physical and mental health and overall quality of life, thus compromising successful aging [38,[71][72][73].
In relation to physical health, we found studies that point to bisexual men as the most engaged and with the best physical health outcomes [15,24]. In these studies, social engagement on the part of bisexual men, and greater isolation on the part of gay men, were determining factors of the results for physical health. In addition, our results may have been influenced by the sample's sociodemographic characteristics, since the majority had an academic background, were employed, and had a medium to high socioeconomic status, characteristics that have already been associated with more successful aging [21,74].
Several determinants of successful aging among OSMM have been identified, such as maintaining social contacts, having less perceived loneliness, and better quality of life [15,75,76]. More than half of the sample were single, living alone, and had no children, which may have been reflected in the homogeneity of the results on social support throughout the sample.
Finally, our linear regressions demonstrated that all study variables were significant predictors of mental health (28%), physical health (18%), and successful aging (10%), with social support being more representative in all of them, followed by resilience and positive identity. These results were expected, due to the positive correlation that we found among all study variables. The results also confirm our research hypothesis about the importance of maintaining these positive factors for more successful aging, thus further corroborating the findings of other studies [24,25,39] and pointing to the need to address these issues in gay and bisexual men's aging strategies.

Limitations and Future Directions
However, this study also has limitations that do not allow for generalization of the results. First, this was a highly differentiated convenience sample, since most participants were employed, educated, single, lived alone, and had no children; thus, they were not representative of the broader Portuguese OSMM population. In addition, we did not control those sociodemographic variables in the regression models, and therefore extraneous factors may be interfering statistically with the results. Future studies should be conducted to control their effects on the dependent variables under study. Second, the majority of the sample self-identified as gay (85.3%), indicating a heterogeneity in the study groups. Third, the survey was disseminated over the Internet through social networks, which may have led to selection bias.
Future studies could benefit from larger and more representative samples, in addition to using other forms of dissemination, such as face-to-face interviews, which could reach other types of participants not included in our sample. Studies that evaluate other aspects, such as socioeconomic characteristics and their impacts on successful aging, could yield a current profile of successfully aging OSMM. Finally, longitudinal studies could assess aging over time, since the aging process is subjective and dynamic and can change according to life experiences [20].

Conclusions and Implications
Despite these limitations, this study provides important contributions to the understanding of successful aging mechanisms among OSMM. These results indicate that, despite the diverse adversities that these men face when dealing with agism and homophobia/biphobia, they are also aging well, with a good perception of physical and mental health, resilience, a positive identity, and positive perceived social support.
In this sense, changing the focus to the positive results of the aging of gay and bisexual men can have an important impact on the advancement of theoretical and practical knowledge for actions that strengthen these factors, which is very important to the strengthening of the LGBT community. In addition, clinical implications can also be taken from these results, as interventions for physical and psychological health of sexual minorities are paramount [77,78]. As such, adopting approaches that encourage positive identity formation [79], resilience development [23], and collaborative work with family, friends, and the LGBT community [38,40] would help to promote social inclusion of OSMM. In addition, it is important to make connections both inside and outside the LGBT communities, ensuring the application of public policies, reducing the negative impacts of prejudice, decriminalization, and stigmatization on older gay and bisexual men, and their overall quality of life [80]. Thus, this study makes a fundamental contribution to the promotion the successful aging of OSMM.
Funding: This research received no external funding.

Institutional Review Board Statement:
The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of the University of Beira Interior Covilhã (Portugal) (protocol code CEUBI-Pj-2020-088).

Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study.

Data Availability Statement:
The data presented in this study are available upon request.