In ruling that the 14th Amendment requires states to issue marriage licenses to same-sex couples and recognize same-sex marriages performed in other states, the U.S. Supreme Court, in Obergefell vs. Hodges, not only addressed a fundamental issue of equality, but may have unwittingly contributed to improved public health.
Consider the research devoted to the health of LGBT (lesbian, gay, bisexual and transgender) populations. A growing body of work shows that their health is worse on multiple levels than the health of comparable majority populations. This work reflects a key foundation of public health that I have discussed previously: Context plays an ineluctable role in shaping the health of populations.
Among LGBT populations, indicators of poorer health include the rate of HIV and the risk of suicide. In the U.S., HIV disproportionally affects gay men, bisexual men and transgender women. Population-based studies in the U.S. have found reported suicide attempt rates among adolescents who identify as LGBT to be two to seven times higher than those of people who identify as heterosexual. A meta-analysis found a two-fold excess in suicide attempts among LGB individuals, a 1.5 times higher risk of anxiety and depression, and a 1.5 times higher risk of alcohol or substance dependence, which was even higher among lesbian and bisexual women. Other studies have shown that LBG individuals, compared to heterosexuals, are more likely to report asthma, overweight, hypertension, diabetes and physical disability, and to self-report poor health. LGBT youth are more likely to be homeless, engage in sex work, and be victims of abuse. Transgender individuals, though studied less, have many health indicators that are even worse than lesbian, gay and bisexual individuals, including HIV (and many do not know their HIV status), suicide attempts, and abuse.
What relevance does marriage equality have to the poorer health of LGBT populations?
Discrimination and marginalization of LGBT populations are almost certainly central mechanisms that explain these differences in health. Consider a study that looked at the connection between perceived discrimination and psychiatric disorders within the same year. The researchers found that lesbian, gay and bisexual individuals had high levels of such perceived discrimination, which was associated with mood, anxiety, and substance use disorders -- interfering with full and productive lives, even when race was taken into account.
Other research posits that chronic stress may result from stigmatization, prejudice, and discrimination, creating a hostile social environment for minorities. Another study, taking the contextual approach to public health, looks at discrimination experienced by individuals and at societal discrimination in terms of access to health insurance, housing, marriage, employment, and retirement benefits. Columbia University Professor Mark Hatzenbuehler and colleagues showed that LGB adults who live in states that lack protection against sexual-orientation-based hate crimes and employment discrimination had a significantly higher prevalence of psychiatric disorders compared to heterosexual adults living in the same states.
LGBT populations may also have less access to care, in part because they distrust authorities. Even when LGBT individuals do have access to care, they often report a lack of culturally competent health care providers. Transgender people in particular may shy away from health care because they cannot afford it or fear being stigmatized. Lack of acceptance among families of LGBT youth may result in isolation from families, which contributes to homelessness and substance use. At the other end of the life-course, elderly LGBT people are less likely to have adult children help them with care and more likely to live alone.
In sum, LGBT populations generally bear a greater burden of disease than their heterosexual counterparts. Much of this difference arises from marginalization of this population due to stigma and discrimination. Marriage equality brings with it legal, financial and structural benefits that come with being part of a fully recognized family unit. Visitation rights at hospitals, rights to accessing information from physicians, being able to add their partners their employer's healthcare plan -- these are all rights that many LGBT partners have long lacked and now will enjoy. Marriage equality, then, is one small step in the right direction towards integrating LGBT populations, removing structural differences that reinforce stigma and countenance marginalization, and moving us closer to a culture of equality that contributes to the better health of all populations.
Sandro Galea, MD, DrPH @sandrogalea
Dean and Professor, Boston University School of Public Health