Does gay marriage improve health?

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Two recent events in the United States have brought the issue of same sex marriage back to the top of the news. Firstly, on election day, 6 November, three states legalized same sex marriage and a fourth voted down a ban on same sex marriage. This brought the number of states that have approved gay marriage to nine.

Secondly, the US Supreme Court announced on 7 December that it would take up two cases relating to same sex marriage. They will hear arguments on the cases in the spring of 2013 and rule on them before adjourning in the summer.

The first case will decide whether California voters acted legally when they passed so called Proposition 8 in 2009, which overruled a decision by the California Supreme Court that had permitted gay marriage.

The second case, from New York, challenges a federal law called the Defense of Marriage Act (DOMA), passed in 1996. DOMA, among other things, defined marriage as between only a man and a woman for the purpose of enforcing hundreds of federal laws and programs. As a result, a woman who was the surviving spouse of another woman had to pay over $300 000 (£185 000; €225 000) in taxes on her spouse’s death, taxes she would not have owed if her spouse had been a man. She sued, claiming unfair discrimination, and a lower court agreed and struck down DOMA. Both sides appealed the case to the US Supreme Court.

The Supreme Court carefully selected these two cases to maximize its options in deciding them. The court could issue a broad decision that either supports Proposition 8 and DOMA, striking down the right to same sex marriage, or overturns the two laws, ruling that the US Constitution requires that states allow gay marriage. Or they could take a narrower approach, focusing on whether states can take away previously conferred rights and requiring that the federal government give equal rights specifically to gay couples who have been married legally. This would result in reinstating gay marriage only in California and would stop well short of a blanket ruling that same sex marriages were legal (or illegal). It would reserve such determinations for the states, which have traditionally been empowered to regulate marriages.

Whether the Supreme Court rules narrowly or broadly, however, it is likely to base at least part of its decision on whether it believes that the plaintiffs have been unfairly denied the rights and benefits of being married. Aside from the financial and tax benefits, this brings up the question of whether marriage has health benefits.

Since the 19th century British epidemiologist William Farr hypothesized that the “conjugal condition” was associated with better health, hundreds of studies have found that married couples lived longer and were healthier than those who were not married. Recent research has found that happily married people were the healthiest of all. Even allowing for concerns about confusing correlation with causality in this research, most authorities agree that married people have a health advantage over divorced and single individuals.1 The obvious question, then, is whether same sex married couples enjoy the same health benefits as heterosexual couples. The emerging answer seems to be yes.

Firstly, same sex marriage extends healthcare insurance to some gay men and lesbians who previously did not have it. Although some employers allow coverage for non-married “domestic partners,” others do not. Also, as previously mentioned, federal benefits in the US do not extend to non-married partners. Unmarried partners of gay men and lesbians are significantly less likely to have health insurance than heterosexual spouses,2 and the literature is clear that uninsured adults have poorer access to care and poorer health than those with healthcare coverage.3

Secondly, studies are starting to find that people in same sex marriages may enjoy better health, as indicated by decreasing health spending by gay men in states where marriage has been legalized. One such study, in Massachusetts,4 found that gay men had significantly decreased healthcare visits and costs in the year after same sex marriage was legalized than in the prior 12 months.

Thirdly, in a study of mid-life and older gay men, the effects of stress on mental health, as measured by self administered stress and depression questionnaires, have been shown to be at least partially ameliorated by being legally married.5 The authors concluded that there were specific mental health benefits of same sex marriage.

Finally, public health commentators have expressed the hope that the increasing availability of same sex marriage would measurably reduce risky behaviors by gay men that have led to the high prevalence of sexually transmitted diseases in this population, ranging from syphilis to HIV infection and AIDS. Understanding HIV and AIDS as “more than simply a biomedical condition”6 that will require more than antiretrovirals to conquer leads to the expectation that decreasing homophobia and discrimination will lead to healthier behaviors by gay men and a decreasing spread and prevalence of HIV.7

As we await the Supreme Court’s arguments and rulings on same sex marriage, it is important to look at all the ramifications of the rights and benefits that are being debated. Marriage equality is not just about a piece of paper. It is about justice, economic discrimination, and dignity. Probably it is about improving the health status of sexual minorities as well.