On Monday, the US 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 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 (lesbian, gay, bisexual, and transgender) Americans. I refer the reader to the Viewpoint in SPH This Week by Professors Raifman and Ulrich, who discuss the legal basis of the court case in more detail.
Despite this irresolution, the case is nevertheless suggestive of core challenges for public 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 recent JAMA Psychiatry study led by 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 last week in Cognoscenti, Professors Raifman and 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.
Since the Supreme Court issued its momentous decision, in Obergefell vs. Hodges, ruling that the 14th Amendment requires states to issue marriage licenses to same-sex couples, it has become clear that there is still work to be done before LGBT Americans can enjoy the full measure of equality that is necessary for a healthy life. Despite his campaign promises to the contrary, Donald Trump’s administration has been consistently hostile to sexual minorities. At the same time, many states have either passed laws advancing LGBT rights or laws that curtail these rights, reflecting a debate that is still very much in flux. Here in Massachusetts, for example, we will vote in November on whether or not to sunset the state’s current law safeguarding the rights of transgender individuals to use spaces of public accommodation. Our school community will continue to engage with this conversation as it unfolds, through our scholarship, our engagement with the media, and our public events. Consistent with this, we today rerun a modified version of a Dean’s Note on LGBT health, with an eye toward building a world where no one is made to bear a disproportionate burden of poor health as a consequence of legal, social, or political marginalization.
There is a growing body of work that shows that the health of LGBT populations is worse on multiple levels than the health of comparable majority populations.This work reflects, much as I have discussed in a previous Dean’s Note, the ineluctable role of context in shaping the health of populations.
Probably the two sentinel health indicators that are poorer among LGBT populations than heterosexual ones are HIV and suicide risk. HIV disproportionally affects gay men, bisexual men, and transgender women in the US. Men who have sex with men make up about two percent of the US population but account for more than half of all prevalent cases and two-thirds of all incident cases of HIV. The rates are highest among black men, increasing 20 percent between 2008 and 2010. Among men who have sex with men diagnosed with HIV by 2010, only 51 percent stayed in treatment for an entire year. One meta-analysis found more than a quarter of US transgender women have tested positive for HIV, and 55 percentof HIV testing events among transgender people take place outside of healthcare facilities (e.g. community centers). In addition to HIV, LGBT people are also at higher risk for syphilis, HPV, and viral hepatitis.
Population-based studies in the US 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 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. 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 in particular, though less studied, 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, and abuse.
Other studies have shown that LBG populations are more likely to report asthma, overweight, hypertension, diabetes, physical disability, and self-reported poor health compared to heterosexual individuals. The Nurses Health Study II found that lesbian women had a higher prevalence of risk factors for cardiovascular disease, including higher BMI, smoking, and greater alcohol consumption. A study using the National Adult Tobacco Survey found that LGBT respondents had comparable exposure to tobacco cessation advertising and awareness and use of cessation methods compared to heterosexual adults, despite higher rates of smoking among LGBT populations.
Sexual minority women (women who have sex with females only or both males and females) have been shown to have a higher lifetime breast cancer risk (although there have been mixed findings). A state-level study (which does not necessarily tell us about individual risk) found that among men, higher bisexual population density was associated with lower incidence of lung cancer and with higher incidence of colorectal cancer. Among women, lesbian population density was associated with lower incidence of lung and colorectal cancer and with higher incidence of breast cancer; however, bisexual population density was associated with higher incidence of lung and colorectal cancer and with lower incidence of breast cancer. A book by our faculty member Professor Ulrike Boehmer, Cancer and the LGBT Community, presents the data about cancer disparities clearly and eloquently.
These data, however, 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 LGBT 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 lifecourse 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 US states that have protection against sexual orientation-based hate crimes and employment discrimination to states that do not, and discovered that LGB adults who live in the states that lack these policies had a significantly higher prevalence of psychiatric disorders compared to both heterosexual adults living in the same states and LGB 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 LGBT 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 LGBT 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 lifecourse, elderly LGBT people are less likely to have adult children 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 disease than their heterosexual counterparts. Much of this difference arises from 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 that 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.
I hope everyone has a terrific week. Until next week.
Sandro Galea, MD, DrPH
Dean and Professor, Boston University School of Public Health
Acknowledgement: I am grateful to Laura Sampson and Catherine Ettman for their contributions to this Dean’s Note.
Previous Dean’s Notes are archived at: https://www.bu.edu/sph/category/news/deans-notes/