As the country awaits two important Supreme Court decisions involving state laws on same-sex marriage, a small but consistent body of research suggests that laws that ban gay marriage — or approve it — can affect the mental health of gay, lesbian and bisexual Americans. When several states passed laws to prohibit same-sex marriage, for example, the mental health of gay residents seemed to suffer, while stress-related disorders dropped in at least one state after gay marriage was legalized.
Here's the research trail:
Beginning around 2004, several states banned gay marriage. Just before that series of bans, the National Institutes of Health happened to conduct a massive survey of 43,093 Americans. The questions elicited detailed information about respondents' mental health. (To validate what people reported about themselves, psychiatrists also interviewed samples of the people in the survey, and their medical diagnoses closely matched the findings of the survey.)
Soon after the wave of state bans on gay marriage, in 2004 and 2005, the NIMH conducted a second round of interviews, managing to reach 34,653 of the original respondents. (That's a high rate compared with most polls and surveys.)
Mark Hatzenbuehler, a psychologist at Columbia University who studies the health effects of social policies, analyzed the data gathered before and after the bans to determine how the mental health of people who identified themselves as gay, lesbian or bisexual had changed in those states.
Hatzenbuehler and his colleagues Katie McLaughlin, Katherine Keyes and Deborah Hasin published their analysis in 2010 in the American Journal of Public Health.
"Lesbian, gay and bisexual individuals who lived in the states that banned same-sex marriage experienced a significant increase in psychiatric disorders," Hatzenbuehler says.
"There was a 37 percent increase in mood disorders," he says, "a 42 percent increase in alcohol-use disorders, and — I think really strikingly — a 248 percent increase in generalized anxiety disorders."
To put those numbers in perspective, although Hatzenbuehler did find more than a doubling in the rate of anxiety disorders in states that eventually banned gay marriage, in absolute numbers he found that anxiety disorders went from being reported among 2.7 percent to 9.4 percent of gay, lesbian and bisexual people.
The million-dollar question is whether the laws, and the debates around them, were responsible for the change in mental health. To help answer that question, Hatzenbuehler and his colleagues looked at comparable groups and experiences.
"We showed the psychiatric disorders did not increase in lesbian, gay and bisexual populations in states that didn't debate and vote on same-sex marriages," Hatzenbuehler says. "There were also no increases — or much smaller increases — among heterosexuals living in the states that passed same-sex marriage bans."
Hatzenbuehler has also found, in a study conducted in Massachusetts, that gay men experienced fewer stress-related disorders after that state permitted gay marriage.
In a study tracking the health of 1,211 gay men in Massachusetts, Hatzenbuehler found that the men visited doctors less often and had lower health treatment costs after Massachusetts legalized same-sex marriage. When the researchers examined the diagnostic codes doctors were giving the men, they saw a decrease in disorders that have been linked to stress, such as hypertension, depression and adjustment disorders.
Hatzenbuehler says he thinks stress associated with gay-marriage debates was the "X factor." He says the quantitative data is backed by what gays, lesbians and bisexuals told the surveyors. "They reported multiple stressors during that period," Hatzenbuehler says. "They reported seeing negative media portrayals, anti-gay graffiti. They talked about experiencing a loss of safety and really feeling like these amendments and these policies were really treating them as second-class citizens."
It's unclear how or whether the upcoming Supreme Court decisions involving the constitutionality of same-sex marriage will affect the mental and physical health of gays and lesbians nationally.
It's likely that many gay, lesbian and bisexual people would see an upholding of same-sex marriage bans as an example of prejudice. But it's also possible the debate around the Supreme Court decisions could have different effects on gays than a local debate involving friends and neighbors.
Hatzenbuehler says his larger point is really that policymakers, judicial leaders and ordinary citizens need to remember that social policies are also health policies.
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DAVID GREENE, HOST:
And I'm David Greene. In a few weeks, the Supreme Court is expected to weigh in on the constitutionality of same-sex marriage. We have heard a lot about the debate. This morning, something different. We're taking a look at whether gay marriage laws have health consequences. NPR's Shankar Vedantam, who regularly joins us to talk about interesting social science research, is in the studio with us. Shankar, welcome back.
SHANKAR VEDANTAM, BYLINE: Hi, David.
GREENE: OK, Shankar. When we talk about bans on same-sex marriage, some talk about it as a matter of prejudice, some talk about it as a matter of tradition in their minds. You're focusing on something different here.
VEDANTAM: That's right, David.
I found some really interesting research that looks at what the mental health consequences are of same-sex marriage bans in the many states that have passed these bans.
GREENE: And we have something like three dozen states with bans in place, right?
VEDANTAM: That's exactly right. And many of these bans were actually enacted around 2004. And it turns out the timing of those bans have given us a natural experiment. Right before 2004, the National Institutes of Health conducted this massive of 30,000 Americans tracking mental health disorders across the country. And then they went after 2004 and spoke to the very same people over again.
I interviewed Mark Hatzenbuehler. He's a researcher at Columbia University. He tracked mental disorders among gays and lesbians before and after states passed these bans on same-sex marriage. And he told me that gay people in states that ban same-sex marriage suffered a significant increase in psychiatric disorders.
(SOUNDBITE OF INTERVIEW)
MARK HATZENBUEHLER: There was a 37 percent increase in moods disorders, a 42 percent increase in alcohol use disorders and, I think really strikingly, a 248 percent increase in generalized anxiety disorders.
GREENE: Two-hundred-forty-eight percent increase in anxiety disorders after bans? That sounds enormous.
VEDANTAM: To put it in perspective, David, he's saying the number of gays and lesbians in these states who had generalized anxiety disorders more than doubled. I mean, so the specific numbers are they went from 2.7 percent to 9.4 percent.
GREENE: After bans took effect.
GREENE: But we should hang on a second. I mean, do we know that these changes were directly related to these laws? Or there could've been a lot of other things going on.
VEDANTAM: Yeah, good question. I asked Hatzenbuehler that and he told me that he tracked the mental health of gays and lesbians who lived in states that didn't pass these bans and he also tracked the mental health of heterosexuals in stated that did pass the bans. And he found these other groups did not see similar increases in mental health problems.
The increase in psychiatric disorders was experienced only by gays and lesbians and only in states that passed the bans.
GREENE: This is what scientists call controlling. I mean...
GREENE: ...nailing it down to one cause of something.
GREENE: OK. On the flip side, Shankar, do we have evidence from states that have approved same-sex marriage?
VEDANTAM: Yes. So Hatzanbuehler conducted one study looking at 1,200 gay men in Massachusetts at a community health center. And he found that after Massachusetts passed a law approving gay marriage, the number of visits to doctors and costs for health care went down. And he found that there was a reduction in disorders that were linked to stress. So disorders like hypertension or depression or adjustment disorders.
GREENE: So it sounds like we're talking about stress, the common denominator. In states that approve same-sex marriage, there's less stress. In states that have banned same-sex marriage, there's more stress among gays and lesbians.
VEDANTAM: Yes. And I think that's exactly what Hatzenbuehler says, and it's also what gays and lesbians in many states that pass these bans are reporting.
(SOUNDBITE OF INTERVIEW)
HATZENBUEHLER: They reported seeing negative media portrayals, anti-gay graffiti. They talked about experiencing a loss of safety and really feeling that these amendments and these policies were really treating them as second-class citizens.
GREENE: And so does this researcher talk about the Supreme Court decisions that are upcoming and what sorts of effects we might see?
VEDANTAM: So, Hatzenbuehler thinks the Supreme Court decisions could have effects on people's mental health but the truth is, I think, David, we don't know for sure. I mean, if the Supreme Court does uphold the ban on same-sex marriage in many states, I think many gay and lesbian people will see it as an act of prejudice.
At the same time, it's also possible that the deliberations of nine people in Washington are going to have very different health effects than the kind of situation where all your friends and neighbors are talking about an issue in a local vote. What's striking about Hatzenbuehler's research, I think, is his larger point, which is something we often forget - social policies really are health policies.
GREENE: Shankar Vedantam often joins us to talk about social science research, and if you want to learn more about this study, this research, you can go on our website npr.org and, Shankar, you're on Twitter, as well, if people want to find you.
VEDANTAM: Indeed. I'm happy to talk to people @hiddenbrain.
GREENE: At-hidden-brain. All right, great. Thanks, Shankar.
VEDANTAM: Thanks, David. Transcript provided by NPR, Copyright NPR.