Published by the New York Times on October 9, 2018
L.G.B.T. people experience a range of social, economic and medical disparities that jeopardize their long-term health.
I’ve never been sure what to expect when meeting someone who’s just tried to take his own life. But I’ve learned to stop expecting anything.
Sometimes, the person in front of me barely speaks, staring right through me, lost in a deep catatonic depression. Sometimes he or she can’t stop talking, breathlessly describing what happened as if we’re gossiping at brunch after an hour of SoulCycle.
Yesterday, my patient, a 20-something graduate student, swallowed a jumble of unmarked pills, hoping to die, after his father told him never to come home again. Today, he greeted me with a soft smile, his delirium starting to clear, his heart beating normally again.
“Whoops,” he said.
He’d been a happy kid who aimed to please. He once felt so bad for lying about having done his homework before playing video games, he told me, that he’d grounded himself. Sociable but square, he didn’t drink until he was 21, even though he’d gone to a college with a reputation for partying. Deeply religious, he was gay but desperately wanted not to be.
Now his father’s disavowal pushed him over the edge, capping a string of stigmatizing experiences at home, at school and at church. He’d had enough.
For decades, we’ve known that lesbian, gay, bisexual and transgender individuals experience a range of social, economic and health disparities— often the result of a culture and of laws and policies that treat them as lesser human beings. They’re more likely to struggle with poverty and social isolation. They have a higher risk of mental health problems, substance use and smoking. Sexual minorities live, on average, shorter lives than heterosexuals, and L.G.B.T. youth are three times as likely to contemplate suicide, and nearly five times as likely to attempt suicide.
Some of these disparities have interpersonal roots: social exclusion, harassment, internalized homophobia. But often they stem from an explicit denial of rights: same-sex marriage bans, employment discrimination, denial of federal benefits. Discrimination in any form can have serious health consequences: Sexual minorities living in communities with high levels of prejudice die more than a decade earlierthan those in less prejudiced communities.
But civil rights advances and growing public acceptance of L.G.B.T. individuals in recent years are among the more transformative social changes in modern American history. And evidence increasingly suggests this shift has measurably improved health care access and health outcomes for L.G.B.T. populations.
The halting, patchwork nature of L.G.B.T. rights expansions across the country has allowed researchers to study the effects on health and well-being by comparing states that expanded rights to those that failed to introduce protections, or actively curtailed them. Since Vermont became the first state to formally recognize same-sex partnerships in 2000, many other states either legalized same-sex marriage, or conversely, passed constitutional amendments banning it — until the landmark 2015 Supreme Court decision in Obergefell v. Hodges required all 50 states to recognize same-sex marriage.
After Massachusetts legalized same-sex marriage in 2003, mental health visits dropped significantly for gay men across the state. Other states that followed suit saw a 7 percent reduction in suicide attempts among L.G.B.T. adolescents. Nationwide, legalization of same-sex marriage is linked toincreases in the likelihood that gay men have health insurance and a regular doctor to see.
By contrast, in states that passed same-sex marriage bans in 2004 and 2006, L.G.B.T. individuals experienced a marked rise in mental health problems, including anxiety, alcohol use and mood disorders. (No such increase was found in neighboring states that did not pass bans.)
Sometimes health happens in the hospital room. Sometimes it happens in a courtroom.
But it’s more than just marriage. L.G.B.T. individuals who live in states where it’s legal for businesses to deny people service based on their sexual orientation have a higher risk for mental health problems. One study found a 46 percent increase in the proportion of sexual minorities reporting depression, anxiety and other emotional problems in states that passed denial-of-service laws. Again, no increase was observed in states without these laws.
But there’s reason to believe progress in L.G.B.T. health may be imperiled by a political and social environment that is growing less friendly toward sexual minorities. More states are trying to pass “religious liberty” laws that allow for discrimination based on gender and sexual identity. Several federal health surveys will no longer include questions about sexual orientation, making it more difficult for researchers to study disparities. And the Trump administration recently established a new division in the Department of Health and Human Services to defend health professionals who refuse to provide care to people or in situations that conflict with their personal beliefs, which could include the right to treat L.G.B.T. individuals. (L.G.B.T. patients already face discrimination at concerning rates: Nearly 10 percent of gays and lesbians — and 30 percent of transgender individuals — say they’ve been refused care because of their sexual orientation or gender identity.)
I think of my young patient in the hospital bed who had attempted to kill himself. I remember the pain that remained even as the toxins he ingested left his body. And I worry that a new wave of anti-L.G.B.T. rhetoric and policy will mean that he — and people who love like him — will end up feeling more stigmatized, in poorer health, or no longer with us at all.
Dhruv Khullar, M.D., M.P.P. (@DhruvKhullar) is a physician at NewYork-Presbyterian Hospital, an assistant professor in the departments of medicine and health care policy at Weill Cornell, and director of policy dissemination at the Physicians Foundation Center for Physician Practice and Leadership.