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Making The Public Health Case For Marriage Equality


The Supreme Court heard oral arguments this week in Obergefell v. Hodges, the same-sex marriage cases that will determine whether individuals of all sexual orientations have the constitutional right to be married in their own states and to have those marriages recognized by other states. As of now, same-sex marriage is legal in 36 states. By the end of June, either same-sex couples will be able to wed in all 50 states, or same-sex marriage bans may be reinstituted in many of the states where they’ve previously been struck down.

Although many states still adamantly resist same-sex marriage, public opinion polls put the approval number nationally at well over 50 percent. The latest ABC News/Washington Post poll found a record 61 percent of Americans support marriage equality. In 2003, only 37 percent did, a strikingly fast reversal. Most Americans view marriage equality as a fundamental civil rights issue — and indeed, it is. But the push for equal rights in marriage is also an issue with profound implications for public health.

History shows that some of the greatest advances in public health, and subsequently the well-being of all people, have been the direct result of increased social justice. The Civil Rights Act of 1964 and Voting Rights Act of 1965 desegregated schools, hospitals, public places and workplaces, and banned discriminatory voting practices. But these laws did more than that — they have also been credited with major public health achievements, including increasing life expectancy and reducing infant mortality for African American women and babies.

Indeed, civil rights are a fundamental determinant of health. There is a profound intersection between social justice and public health, and in order to achieve one, we must also have the other. Nothing speaks to this more than the fact that social differences that result from inequalities (i.e., disparities)—in areas such as income, education, neighborhood conditions and the experiences of stigma and discrimination—actually have a greater impact on the health of an individual than even medical care.

Disparities and Discrimination

Today, the Lesbian Gay Bisexual and Transgender (LGBT) population suffers from poorer health than the heterosexual population. Risk of poor mental health outcomes, including the likelihood of general psychological distress, depression, anxiety, the need for psychiatric medication and the risk for suicide attempts is significantly higher for the gay and lesbian population, particularly among youth. LGBT individuals also have markedly worse physical health outcomes, including higher rates of a number of chronic conditions, poorer self-reported health status, and higher prevalence and earlier onset of disabilities; they are also more likely to develop cancer and, subsequently, to die from it. Members of the LGBT community are less likely to have health insurance and more likely to delay or not seek care, to go without needed prescription medication and to receive health care in emergency rooms. The largest disparities, however, are found in the statistics on HIV: gay and bisexual men, who comprise just two percent of the U.S. population, account for a staggering 63 percent of new HIV infections and 78 of diagnoses among all newly infected men, according to the Centers for Disease Control and Prevention. And as rates for other groups were falling, from 2008 to 2010, new HIV infections increased 22 percent among young gay and bisexual men and 12 percent among gay and bisexual men overall.

Stigma and a long history of institutionalized discrimination are at the heart of these poor health outcomes. In the majority of states in the country, it is still legal to discriminate against the LGBT population in the areas of employment, housing and public accommodation. And according to the American Civil Liberties Union, “[t]here are bills in state legislatures across the country that could allow religion to be used to discriminate against gay and transgender people in virtually all aspects of their lives.”

Religious Freedom Restoration Acts, which exempt individuals and companies from non-discrimination rulings by the courts based on their religious beliefs, have been passed in two states (Indiana and Arkansas) and introduced in five others in 2015 alone. Marriage refusals — laws that permit various kinds of refusals regarding same-sex marriage, such as those that 1) allow judges, clerks, magistrates and other people authorized by the state to refuse to perform marriages and/or issue marriage licenses; 2) permit individuals, businesses and/or religious organizations to refuse to provide goods and services to same-sex couples and/or refuse to treat marriages as valid based on their religious beliefs; and 3) override the federal courts’ constitutional decisions on marriage for same-sex couples — have been introduced in seven states, passed by at least one body of the state legislature in three states, and enacted into law in one state (Utah) over the past four months. Several states, including Texas, South Carolina and Missouri, introduced multiple types of marriage-refusal laws.

Meanwhile, four states are considering a total of seven different bills aimed at restricting adoption & foster care rights among LGBT individuals, one state is considering two different bills impeding on LGBT individuals’ access to health services, two states are considering three bills that would allow colleges and universities to fund student groups that discriminate against LGBT students, and one state is considering legislation that would override existing federal and state policies and allow government contracts to go to discriminatory contractors. At least ten other anti-LGBT bills have been introduced in six states since the start of 2015. These include laws allowing businesses to discriminate, a proposal to eliminate marriage licenses altogether, and laws that would ban local nondiscrimination ordinances.

LGBT individuals also find themselves subject to countless other forms of discrimination that are written into laws and constitutional amendments grounded in the 1996 Defense of Marriage Act, which defined marriage as a legal union solely between a man and a woman. The obvious inference is that same-sex marriage is somehow of lesser value than is heterosexual marriage; the underlying fear is often that marriage equality will actually cause societal harm. Being cast in such a light strongly contributes to the phenomenon known as “minority stress,” which is defined by a “culture of devaluation, including overt and subtle prejudice and discrimination, [one that] creates and reinforces the chronic, everyday stress that interferes with optimal human development and well-being.”

Strikingly, the minority stress experienced by the LGBT population has been directly linked to mortality. In a 2014 study published in the journal Social Science & Medicine, researchers found that the life expectancy of LGBT individuals living in communities with high levels of anti-LGBT prejudice was twelve years lower than for those living in less-prejudiced communities. The authors concluded: “Our findings indicate that sexual minorities living in communities with higher levels of prejudice die sooner than sexual minorities living in low-prejudice communities, and that these effects are independent of established risk factors for mortality, including household income, education, gender, ethnicity, and age, as well as the average income and education level of residents in the communities where the respondents lived.”

Bans on Same-Sex Marriage: A Threat to Public Health

Being denied the right to marry further reinforces the stigma associated with a minority sexual identity, and can particularly undermine the healthy development of a well-adjusted emotional and social attachment style among adolescents and young adults. Research clearly illustrates the harmful psychological effect of policies restricting marriage rights for same-sex couples. For example, studies have consistently shown that gay men and lesbians exposed to the stigma of homosexuality have a higher risk of experiencing distress and adverse psychological outcomes. According to a study of In one study of more than 1,500 LGB participants, researchers found that living in a U.S. State where same-sex marriage is outlawed was directly related to chronic social stress and psychological problems, and not due to pre-existing mental health issues or other factors.

In the most extensive study on the issue to date, researchers at the National Institutes of Health conducted a survey of over 34,000 Americans, asking detailed questions about mental health. Data for the study were collected in two waves, first in 2001-2002 and again in 2004-2005. The second wave of data collection took place shortly after 14 states had voted to ban gay marriage, which allowed the researchers to assess how the mental health of the LGBT population had changed in those states. The study, published in 2010 in the American Journal of Public Health, found that “[LGBT] individuals living in the states that banned same-sex marriage experienced a significant increase in psychiatric disorders,” including:

  • 37% increase in mood disorders;
  • 42% increase in alcohol-use disorders; and
  • a whopping 248% increase in generalized anxiety disorders

There were no similar increases in psychiatric disorders among gays and lesbians in states that did not pass gay marriage bans, and, the researchers wrote, “[t]here were no increases– or much smaller increases– among heterosexuals living in states that passed same-sex marriage bans.” In other words, it’s very likely that that same-sex marriage bans were responsible for the rise in psychiatric disorders among LGBT Americans.

And beyond the negative effect of marriage restrictions for gay, lesbian and bisexual individuals, recent research indicates that the families of origin and allies of sexual minorities may suffer from some of the same serious negative physical and mental health consequences experienced by their loved ones. This includes children of same-sex couples who are denied the opportunity and benefits of marriage.

The Public Health Benefits of Marriage Equality

Establishing equal marriage right would help reduce these disparities and improve the health of thousands of LGBT people across the country. Marriage has been shown to lead to both physical and mental health benefits and a longer life expectancy, and experts say LGBT couples who have the same option to marry can expect long-term health benefits through the increase in social support, the financial benefits of marriage, decreased stigma and discrimination, and the protective effects of a stable relationship and increased intimacy.  “Marriage appears to confer a number of benefits, psychological and otherwise,” explained Dr. Letitia Anne Peplau, a social psychologist and researcher at UCLA. “There isn’t anything in the scientific literature that suggests that gay or lesbian people would benefit less or differently than heterosexual people from access to the institution of marriage.”

Predictably, studies of the impact of the legalization of same-sex marriage in other states already show health benefits.

In a 2012 study published in the American Journal of Public Health, researchers found that gay men in Massachusetts were in better physical and mental health after that state became the first to recognize same-sex marriage in 2003. Researchers examined the medical records of 1,211 gay and bisexual men who went to “a large, community-based health clinic” in a “large metropolitan city” and compared the patients’ use of medical services before and after the law went into effect. Men in the study went to the clinic for a medical problem an average of 2.61 times in the 12 months before same-sex marriage was legalized; in the 12 months after the law passed, that average dropped to 2.26 times. The money spent on medical care also dropped, from $259.32 per patient, on average, to $233.09, the researchers found. Mental health improved as well, according to the study. The number of visits to the clinic related to a mental health issue dropped from 3.35 per patient, on average, to 2.93, while mental healthcare costs fell from $331.08 to $283.59. Overall, the number of visits to the clinic fell by 13 percent after gay marriage was legalized – and both partnered and single gay men benefited, the researchers found. “One mechanism that may explain these findings is a reduction in the amount and frequency of status-based stressors that sexual minority men experience when institutionalized forms of stigma are eliminated,” they wrote.

Another 2012  report, also published in the American Journal of Public Health, used data on 202 gay men participating in an longitudinal study at UCLA. The study’s main purpose is to track the mental health of older gay men (ranging in age from 44 to 75) as they deal with the stigma of being in a sexual minority as well as the emotional toll of dealing with HIV and AIDS. The researchers also took advantage of the fact that gay marriage was legal in California between June and November of 2008. The study showed that men who were legally married to men were more likely than other gay men to have a “positive affect,” meaning that they were more apt to be “relaxed,” “calm” and “peaceful” and to feel hopeful for the future, among other psychological measures. Gay men in domestic partnerships did not get the same boost, the researchers found. Likewise, gay men with legal husbands were also less likely to be depressed, according to the study. The same was not true for gay men in domestic partnerships

Not only is marriage associated with positive health outcomes for all individuals, regardless of sexual orientation; in addition, same-sex marriage has not been demonstrated to adversely affect the institution of heterosexual marriage — a fact that refutes one of the central arguments of those who oppose marriage equality. In 2007 the Centers for Disease Control and Prevention reported that all five states allowing same-sex marriage had divorce rates nearly 20 percent lower than those found in the rest of the country. Longer-term experience with same-sex marriage in Scandinavia and the Netherlands lends further support to these statistics. Furthermore, same-sex marriage does not diminish the prospect of successful parenting. It is well-established that children raised by same-sex couples compare favorably with other children in all performance standards assessed; the most important predictor of successful child-rearing is an intact two-parent unit.

It is for these reasons that every major medical association in the country — including the American Medical Association, the American Academy of Pediatrics, the American Academy of Family Physicians, the American Psychological Association, and the American College of Obstetricians and Gynecologists — have issued position statements in support of marriage equality, citing the health benefits of marriage and the harm caused by banning same-sex marriage.

The Supreme Court has repeatedly said that marriage is a fundamental right that the state cannot abridge without some real justification. It has said that prisoners have the right to marry, and most famously, in 1967, it struck down state bans on interracial marriage — showing that, despite claims to the contrary, the institution of marriage has been evolving since long before same-sex marriage came on the scene. Marriage was once culturally defined as the legal union of a man and a woman of the same ethnicity, race, religion, or social status, and it promoted a male-dominated unequal relationship; now marriage embodies interracial and interreligious partnerships with gender roles blurring, in striking contrast to the marriage of our forebears.

Now, the Supreme Court must decide whether to accept this evolving concept of marriage, or to reject it. By extending equal marriage rights to everyone, the court has the opportunity to promote historic advances in public health and health equity that would improve millions of lives. But by withholding these rights from same-sex couples, the Supreme Court would be condemning a class of Americans to suffer from the preventable health disparities that have already cut short the lives of far too many.



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