Public Health Implications of Same-Sex Marriage

MINORITY STRESS

One only has to consider the rash of recent teen suicides resulting from antigay bullying to begin to comprehend the magnitude of the public health problem faced by this country and its LGBT sexual minority. Despite the prevalence of same-sex households and campaigns to protect human rights, gay persons find the very nature of their being constantly debated within our legislative bodies, the courts, and the mainstream media. They are subject to ridicule and are commonly the targets of demeaning and derogatory slang terms or insensitive jokes. Their morality and value as human beings are frequently questioned by individuals and organizations ignorant or unaccepting of current medical and social science literature concerning the gay population.

LGBT individuals also find themselves subject to laws or constitutional amendments supported by 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 members of this community experience in their struggle for validation and acceptance in our heterosexist society.

Unique to the LGBT form of minority stress—as opposed to minority stress engendered by societal prejudice based upon race, ethnicity, gender, or disability—is that one's sexual orientation usually is invisible to others. As a result, in addition to being the target of overt discrimination, LGBT individuals are constantly subject to subtle, inadvertent, or insensitive attacks on the core of their very nature, even by people who profess no disdain or disrespect for them. For instance, if someone has a lesbian colleague but doesn't know the colleague's orientation, an innocent question—such as asking her if she has a boyfriend, rather than asking “Are you seeing someone special?”—implies a judgment regarding what is “normal.” When the “other” is invisible, faceless, or nameless, it is common for those in power to ignore the reality of the other's existence and the challenges the other faces. This interplay of power and prejudice, whether overt or covert, constitutes the phenomenon of heterosexism. Similarities to the racism and sexism so prevalent during the civil rights movements of past generations are obvious.

INTERNALIZING PREJUDICE

This sexual-minority status, as explained by Riggle and Rostosky, 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.³

LGBT individuals, stigmatized by negative societal attitudes directed at the essence of their being, struggle on a daily basis to balance the dual dangers of publicly engaging their need for equality and validation and remaining closeted to find some calm through an escape from public scrutiny.⁴ Many gay persons internalize such discrimination and prejudice. Fractured social-support mechanisms and minority-stress–associated low self-esteem contribute to a high prevalence of self-destructive behaviors, such as substance abuse, suicide, and risky sexual behavior.^5–10

Hatzenbuehler et al. studied more than 34 000 lesbian, gay, and bisexual participants and found empirical evidence of the negative health effects of discriminatory policies relative to marriage equality.¹¹ They surveyed participants in 2001 and 2002 on a range of psychological health indicators, and they administered the same survey in 2004 and 2005, after 14 states approved constitutional amendments limiting marriage to opposite-sex unions. In the second set of responses, participants reported significantly higher rates of psychiatric disorders, with increases of 36% for any mood disorder, 248% for generalized anxiety disorder, 42% for alcohol use disorder, and 36% for psychiatric comorbidity. In the comparable control group from states without such amendments during the same time period, there were no significant increases in these psychiatric disorders.¹¹

Although causality may be difficult to establish, the association and prevalence of these disorders suggest that institutionalized stigma and its attendant internalized prejudice (i.e., minority stress) stand at the forefront of this cycle, begetting higher rates of sexually transmitted diseases, depression, suicide, and drug use—all of which, when combined with suboptimal access to health care and fractured family-support systems, eventually contribute to higher overall mortality as well as morbidity from various cancers, cirrhosis, hypertension, and heart disease.

We know that legally married couples, regardless of socioeconomic factors, have significantly lower incidences of such mental and physical diseases than do unmarried persons^12–15; but how can we truly know, or reasonably expect, that marriage equality would, in fact, confer such health benefits upon the LGBT community? Why are legally married individuals healthier than their single counterparts? The answer, it turns out, is complex and multifactorial, with its explanation drawing from the disciplines of medicine, economics, politics, sociology, and psychology.

HEALTH BENEFITS OF MARRIAGE

Better access to health care is known to translate into lower mortality. Wilper et al. reported in 2009 that uninsured adults have a 40% higher relative risk of death than do insured adults (after multivariate analysis controlling for demographic, health, and socioeconomic status).¹⁶ In a recent study by Ponce et al. evaluating the effects of unequal access to health insurance for same-sex couples in California, partnered gay men and partnered lesbians had significantly lower likelihoods (42% and 28%, respectively) of receiving employer-sponsored dependent coverage than did their married heterosexual counterparts.¹⁷ Furthermore, unlike dependent benefits that workers acquire through heterosexual marriage, the federal government and most affected states classify benefits received by domestic partners, civil-union spouses, and same-sex spouses as taxable earned income.¹⁷,¹⁸ The financial consequences did not stop at the individual level; Ponce et al. further note that “the effect of restrictive, differential treatment of same-sex relationships pushes the costs … into the public domain,” with HIV-seropositive men twice as likely to depend upon public insurance because of lack of access to affordable insurance.¹⁷

Testimony at the Perry v Schwarzenegger trial—in which a federal judge heard a suit challenging the constitutionality of California's Proposition 8, which amended the state's constitution to prohibit same-sex marriages—detailed the economic advantages of marriage in terms of specialization of labor, reduced transition costs, economies of scale, and health insurance and survival benefits, to name a few. However, the psychology involved for married individuals may be even more significant. Expert witnesses cited the self-perceived benefits of marriage equality reported by gay and lesbian married couples in Massachusetts, as reported by the Massachusetts Department of Public Health: as a result of the legal recognition of same-sex marriage, 72% felt more committed to their partners, and 70% felt more accepted by their communities, while 93% of children with same-sex parents reported feeling happier and better off.¹⁹

The testimony and conclusions of those witnesses are validated by the accumulating evidence-based literature. Rothblum et al. studied 216 lesbians and 123 gay men who had had civil unions in Vermont compared with 166 lesbians and 72 gay men who had not had civil unions. Gays in civil unions had significantly greater contact with and social and emotional support from their families and friends.²⁰ They were more likely to remain in their long-term committed relationship if it was a legally recognized relationship.²¹ In so doing, they had better access to health insurance and quality health care as well as more consistent family support, which is vital to one's emotional health.²²

Fingerhut and Maisel studied 239 individuals involved in same-sex relationships, and they found that social recognition and legal recognition of same-sex marriage were differentially associated with individual and relationship outcomes.²³ They found that legally recognized same-sex marriage conferred the same benefits experienced by heterosexual couples that move from cohabitation to legal marriage. Those who were married reported significantly less depression and anxiety, and better psychological well-being. Social formalization through a public ceremony involving a community of support served to “reduce feelings of stigmatization or marginalization.” The gay couples studied reported enhanced relationship satisfaction and a strengthened sense of commitment to one another when legal formalization provided a barrier to dissolution.

Such commitment has practical health benefits. Klausner et al. analyzed data obtained from a survey of 2881 gay men in four major metropolitan areas of the United States and concluded that “same-sex male civil unions are associated with lower-risk behavior for HIV infection and other STDs … suggesting that societal and legal recognition have an impact on the maintenance of safer sex behaviors.”²⁴ The consensus of social science experts is that marriage confers health benefits, regardless of the fact that healthier people may self-select into marriage.^22,25

Thus, the health benefits conferred by legalized marriage are significant regardless of the sexual orientation of the individuals involved. The practical aspects of legalized marriage provide important financial security and stability. The social aspects of publicly formalizing one's commitment to another creates a community of support that provides benefits far exceeding those available to couples who only cohabit. The improved psychological well-being conferred by such support clearly has a protective effect on the health of those individuals.²²

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. In 2007 the Centers for Disease Control and Prevention reported that all five states allowing same-sex marriage had divorce rates nearly 20% lower than those found in the rest of the country.²⁶ Longer-term experience with same-sex marriage in Scandinavia and the Netherlands lends further support to these reassuring statistics.²⁷

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.^28–31

Pediatricians, psychiatrists, psychologists, anthropologists, and social workers have long recognized that one's social environment plays a significant role in determining one's psychological health. Position statements from numerous professional associations further support the claim that the LGBT community would receive significant health benefit if committed same-sex relationships were afforded the social validation and legal status of committed heterosexual relationships.^3,5,32–35

LIMITATIONS

Census data are limited by the self-reported nature of the data collection, which is dependent upon the willingness of those surveyed to identify themselves as gay. Though the census is presented as an anonymous data-collection process, those who are suspicious of government or who fear the potential consequences of public acknowledgment of their orientation may not report their orientation correctly, causing incomplete reporting of LGBT prevalence. Furthermore, US census questionnaires do not clearly define what it means to be gay. This lack of clarity may contribute to the widely disparate estimates of the actual prevalence of gays and lesbians in our society. With estimates ranging from 2% to 10% of the general population, it is worth noting that if “gay” were defined as same-sex attraction or experience, prevalence would be substantially higher than if it were defined by self-identification as being gay.

Regardless of prevalence, another limitation is the lack of extended longitudinal experience with the phenomenon of same-sex marriage, given that it first occurred in Denmark in 1989 and only more recently in the United States. Further time and study are clearly warranted in the ongoing assessment of the more widespread implications associated with embracing marriage equality.

In addition, demographic surveys and their interpretation are subject to investigator bias. It is important to acknowledge that when we look at books, scriptures, and even evidence-based literature, we tend to see what is already inside us. The study of an emotionally charged social issue, such as marriage equality, is fraught with such potential pitfalls; and despite academic rigor and the peer-review process, the results of such studies may ultimately be flawed.

CONCLUSIONS

“Do not believe in anything simply because you have heard it. Do not believe in anything simply because it is spoken and rumored by many. Do not believe in anything simply because it is found written in your religious books. Do not believe in anything merely on the authority of your teachers and elders. Do not believe in traditions because they have been handed down for many generations. But after observation and analysis, when you find that anything agrees with reason and is conducive to the good and benefit of one and all, then accept it and live up to it.”

—Buddha³⁶

The institution of marriage is evolving, but this was true well 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. Formal, legal marriage confers survival advantages to heterosexuals regardless of race/ethnicity, religion, or socioeconomic status. The recent medical and social science literature cited here assures us that the same holds true for gays and lesbians who are given the opportunity to enter into legal marriage.

While fully acknowledging the limitations described earlier and the uncertainties inherent in such discussions, the Indiana State Medical Association—on the basis of the evidence-based literature cited in this article, including research from academic experts in the fields of medicine, economics, political science, psychology, epidemiology, and public health—has joined the American Medical Association in calling for the recognition that exclusion from civil union or marriage contributes to health care disparities affecting same-sex households. The Indiana State Medical Association resolution also calls for us to “work to reduce health care disparities among members of same-sex households, including minor children” and to “support measures providing same-sex households with the same rights and privileges to health care, health insurance, and survivor benefits, as afforded opposite-sex households.” For a state such as Indiana to put aside tradition in favor of a position that “after observation and analysis … agrees with reason” suggests that we have reached a tipping point in the debate over marriage equality and its societal impact.

It remains to be seen when other states will follow suit, but the results of this literature review strongly suggest that the legal and social recognition of same-sex marriage are likely to impart more than just symbolic support for the gay community. Embracing marriage equality through education and legislation is sound public health policy supported by evidence-based literature. Legislation to make marriage equality a reality will change, and save, lives.