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LGBT Health Is Inseparable from LGBT Rights

More equality means better health.

It's Pride Month, a time for celebrating the LGBT (lesbian, gay, bisexual, and transgender) community. LGBT individuals have made significant strides toward greater equality, notably with the 2015 passage of marriage equality in the U.S. Yet this population continues to face a range of mental health challenges, many of which are linked to conditions of marginalization.

Last year, the Supreme Court decided the case of Masterpiece Cakeshop vs. Colorado Civil Rights Commission. The origins of the case lay in a baker’s religion-based objection to serving a same-sex couple wishing to buy a cake for their wedding. The Court’s decision favored the baker, ruling on procedural grounds that he did not receive a fair hearing from the Colorado Civil Rights Commission, members of which had used language that former Justice Kennedy, writing the Court’s majority opinion, said constituted evidence of “hostility to religion.” In this sense, the ruling was quite narrow, leaving unresolved the larger question of whether or not it is constitutional for businesses to deny services to LGBT Americans.

Despite this irresolution, the case is nevertheless suggestive of core challenges for health—in particular, the health gaps that can emerge from imbalances of equity fostered by discriminatory laws. Data have shown a link between discriminatory policies and poor health. In a JAMA Psychiatry study led by Boston University School of Public Health Professor Julia Raifman, we found that state laws permitting denial of services to same-sex couples are associated with a 46 percent increase in the proportion of sexual minority adults who experience mental distress. Writing in Cognoscenti, BUSPH professors Raifman and Michael Ulrich contextualize this statistic among the broader health challenges faced by sexual minority populations—which include higher rates of suicide and mental distress than their heterosexual peers—as well as the discriminatory practices faced by these populations in many states.

There is a growing body of work that shows that the mental health of LGBT populations is worse on multiple levels than the mental health of comparable majority populations. 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 compared to those who identify as heterosexual. Sexual orientation may be a particularly strong predictor of suicide attempts among male adolescents. A meta-analysis found a two-fold excess in suicide attempts among LGBT individuals, a 1.5 times higher risk of anxiety and depression, and 1.5 times higher risk of alcohol or substance dependence, which was even higher among lesbian and bisexual women. In the Nurses’ Health Study II, lesbian women were more likely to report depression and the use of antidepressants. A study of middle-aged adults revealed that gay and bisexual men experienced more panic attacks and depression than heterosexual men and that lesbian/bisexual women had a higher prevalence of generalized anxiety disorder than heterosexual women. Transgender individuals, though less studied, have many mental health indicators that are even more troubling than those of lesbian, gay, and bisexual individuals, including suicide and abuse.

These data call for careful attention to the mechanisms that explain the health disparities between LGBT and heterosexual populations. Namely, why should LGBT populations have different health than comparable majority populations?

At heart, discrimination and marginalization of sexual minority populations is almost certainly a central mechanism explaining these differences. A study using the 2004–2005 National Epidemiologic Survey on Alcohol and Related Conditions found that lesbian, gay, and bisexual individuals had high levels of past-year perceived discrimination, which was associated with past-year mood, anxiety, and substance use disorders. Similarly, the National Survey of Midlife Development data showed that LGB individuals reported more lifetime and daily experiences of discrimination and that almost half attributed the discrimination to their sexual orientation. This perceived discrimination was associated with having a psychiatric disorder and interfering with a full and productive life, even when stratified by race.

The minority stress model posits that chronic stress may result from stigmatization, prejudice, and discrimination, creating a hostile social environment for minorities. A 2011 Institute of Medicine report emphasized the complex influences on LGBT health, including the minority stress model, along with a life course perspective, an intersectionality perspective (which considers different aspects of an individual’s multiple identities), and a social ecology perspective (which considers outside spheres of influence including families, communities, and society at large). An example of the social ecology perspective considers individual experienced discrimination and societal discrimination in terms of access to health insurance, housing, marriage, employment, and retirement benefits. Mark Hatzenbuehler and colleagues compared U.S. states that have protection against sexual orientation-based hate crimes and employment discrimination to states that do not, and discovered that sexual minority adults who live in states that lack these policies had a significantly higher prevalence of psychiatric disorders compared to both heterosexual adults living in the same states and sexual minority adults in states that did have protective laws.

LGBT populations may also have less access to care, in part influenced by stigma and distrust of authorities. The National Health Interview Survey reported that women in same-sex relationships were less likely than women in heterosexual relationships to have health insurance or to have seen a medical provider in the past year, and more likely to have unmet medical needs. 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 be distrusting of health care due to stigma and affordability.

In perhaps a singularly good illustration of the pervasive influence of stigma and marginalization, it has been shown that while sexual minority populations do not differ from their heterosexual counterparts in their desire to quit smoking cigarettes or their awareness of quitting programs, minority stress or discrimination may be contributing to elevated smoking rates in sexual minority populations.

Lack of acceptance among families of LGBT youth may result in isolation from families, both of which contribute to homelessness and substance use. At the other end of the life course, elderly LGBT people are less likely to have adult children to help them with care and more likely to live alone. One study of transgender adults and their non-transgender siblings found that the transgender siblings reported less perceived social support from the same families.

In sum, LGBT populations generally bear a greater burden of mental illness than their heterosexual counterparts. Much of this difference arises from the marginalization of this population due to stigma and discrimination. Marriage equality brought with it legal, financial, and structural benefits that come from being a part of a fully recognized family unit. Visitation rights at hospitals, rights to accessing information from physicians, being able to add your partner to your employer’s healthcare plan—these are all rights that many LGBT partners have long not enjoyed, and now do. Marriage equality, then, was one 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 among groups, which contributes to the health of all populations. The next step, surely, is ensuring that the basic civil rights of sexual minorities are protected, so that their health may not only improve but flourish.