State Laws Permitting Denial of Services to Sexual Minorities Increase Mental Distress

State laws that permit denial of services to same-sex couples or other sexual minorities are associated with a 46% increase in mental distress among sexual minority adults, according to the results of a study published in JAMA Psychiatry.

Sexual minorities experience depression, anxiety, mental distress, and suicide attempts at a higher rate than heterosexual individuals. Currently, 12 states have implemented laws allowing the denial of services to sexual minorities, including gays, lesbians, bisexuals, or those not sure of their sexual orientation. Evidence indicates that stigma related to sexual orientation is associated with poorer mental health outcomes.

Julia Raifman, ScD, of Boston University School of Public Health in Boston, Massachusetts, and colleagues used a difference-in-difference-in-difference linear regression analysis to evaluate whether state laws permitting individuals to refuse services to sexual minorities were associated with adverse effects such as mental distress. They used Behavioral Risk Factor Surveillance System (BRFSS) data from 2014 through 2016 from adults aged 18 to 64 years in Utah, Michigan, and North Carolina, 3 states that implemented laws allowing the denial of services to same-sex couples, and from 6 nearby control states — Idaho and Nevada, Ohio and Indiana, and Virginia and Delaware. The primary outcome was mental distress, defined as poor mental health on 14 or more of the previous 30 days.

Data were gathered from 109,089 individuals, 4.8% of whom identified as sexual minorities. In 2014, 12.6% of heterosexual adults and 21.9% of sexual minority adults reported mental distress. In states that passed laws permitting denial of services to sexual minorities, the percentage of sexual minority adults reporting mental distress increased by 10.1 percentage points between 2014 and 2016 compared with control states. This represents a 46% relative increase in mental distress among sexual minority adults (P =.046).

The authors suggest a number of potential mechanisms by which mental distress might increase in sexual minorities, including refusal of a marriage license or adoption, learning of such a refusal from a friend or social contact, perception of sexual minorities as second-class citizens by the general population, and media coverage and discussion of state laws permitting denial of services. To put the 46% increase in mental distress into perspective, the authors noted that undocumented immigrants who received Deferred Action for Childhood Arrivals status, which prevented deportation and allowed temporary work permits, experienced a 48% reduction in mental distress.

Among the study’s limitations, the authors cited the inability to evaluate baseline trends in mental distress prior to 2014 in this minority population.

The authors suggest that lawmakers and courts considering implementing laws permitting denial of services to sexual minorities should also consider the relationship between such laws and increased mental distress in this population.

Reference

Raifman J, Moscoe E, Austin SB, Hatzenbuehler ML, Galea S. Association of state laws permitting denial of services to same-sex couples with mental distress in sexual minority adults [published online May 23, 2018]. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2018.0757