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All things being equal…

To some, same-sex marriage is simply a matter of equal rights — the view that gay couples should be afforded the same rights as heterosexual couples. But the health argument is also a compelling one, with studies pointing to the psychological and other health benefits for such couples when their marital status is legalised.

Numerous health studies over the past decade have suggested how the denial of gay people’s right to marry can lead to significant health disparities. The message is that this may provoke or exacerbate feelings of rejection, shame, low self-esteem and depression, sometimes triggering alcohol or drug abuse.

According to a 2013 study in Australia, which has been grappling in recent years with the issue of legalising gay marriage, denying lesbian, gay, and bisexual adults access to a key social institution effectively makes them second-class citizens and can have a profound impact on their health and well being and that of their families.

The study found that gay Australians seeking to affirm their rights are more likely to experience below-average health outcomes, including higher levels of depression due to this prejudice and discrimination. “The statistics are particularly alarming for younger and newly-identifying LGBT people who have consistently higher rates of drug and alcohol abuse, homelessness, early school-leaving, conflict with peers and parents and suicide ideation, all directly related to the discrimination and prejudice they experience,” the study stressed.

The decision by the American Psychological Association (APA) in 2011 to support same-sex marriage was prompted by a number of studies showing the direct link between legal bans on same-sex marriage and higher levels of stress and anxiety, lower self-esteem, and greater incidence of mental and physical health problems among gay people. “Anything other than marriage is, in essence, a stigmatisation of same-sex couples. Stigma does have negative impacts on people,” the Association declared.

It had earlier rejected the notion that civil or domestic partnerships met the social and psychological needs of gay couples. “Same-sex couples who enter into a civil union are denied equal access to all the benefits, rights and privileges provided by federal law to those of married couples … The benefits, rights, and privileges associated with domestic partnerships are not universally available, are not equal to those associated with marriage and are rarely portable… The APA believes that it is unfair to deny same-sex couples legal access to civil marriage and to all its attendant benefits, rights and privileges.”

In the United States, same-sex couples can legally marry in 37 of the 50 states and in June 2013, the Supreme Court moved closer to recognising gay marriage nationally when it ruled it as unconstitutional for the federal government to deny federal benefits of marriage to married same-sex couples if the marriage is recognised or performed in a state that allows same-sex marriage.

Dr Iain Jordan

Several studies have reported disparities in health and access to care for lesbian, gay and bisexual people living in states that ban same-sex marriage through constitutional amendments. Lesbian, gay and bisexual adults living in such states are more likely than their counterparts in same-sex marriage to report symptoms of depression, anxiety and alcohol abuse.

A study in the American Journal of Public Health in June 2011 on the ‘Public Health Implications of Same-Sex Marriage’ concluded more American states should legalise gay marriage. “Paediatricians, psychiatrists, psychologists, anthropologists and social workers have long recognised that one’s social environment plays a significant role in determining one’s psychological health. Position statements from numerous professional associations further support the claim that the LGBT community would receive significant health benefit if committed same-sex relationships were afforded the social validation and legal status of committed heterosexual relationships,” said the author Dr William Buffie.

“It remains to be seen when other states will follow suit, but the results of this literature review strongly suggest that the legal and social recognition of same-sex marriage are likely to impart more than just symbolic support for the gay community. Embracing marriage equality through education and legislation is sound public health policy supported by evidence-based literature.”

In 2010, a study in New York by Columbia University Mailman School of Public Health, examining the effects of institutional discrimination on the psychiatric health of lesbian, gay and bisexual individuals, found an increase in psychiatric disorders, including a more than doubling of anxiety disorders among the LGBT population living in states that instituted bans on same-sex marriage. According to the author, the study highlighted the importance of abolishing institutional forms of discrimination, including those leading to disparities in the mental health and wellbeing of LGBT individuals.


In Ireland, the evidence is that people suffer mental health problems related to their sexuality but not due to their sexuality; these issues can relate directly or indirectly to societal attitudes to their sexuality, according to Dr John Hillery, Director of External Affairs of the College of Psychiatrists of Ireland. “Thus, legal recognition of relationships should have a positive effect on mental health,” he tells the Medical Independent (MI).

Emphasising that available literature seems to apply to legal recognition of same-sex partnerships and does not seek to examine a difference between the effect of civil partnerships and full marriage, Dr Hillery adds: “The full gamut of mental health problems are more likely in any marginalised group. It is well recognised that positive, long-standing relationships have a positive effect on mental health and that the lack of such has the opposite [effect]. Obviously, legal recognition of relationships must strengthen the tenability and acceptance of relationships and thus have a positive effect.”

Asked to comment on US studies showing savings in healthcare costs associated with gay rights, and whether this might also be a benefit for Ireland’s healthcare costs if the marriage equality referendum is passed, Dr Hillery says he did not have specific data for the costs to healthcare specific to the gay and lesbian population in Ireland. He does, however, go on to make the general point that “mental ill health costs the economy vast amounts every year, either directly through costs of care or indirectly through its effects on people’s ability to take a full and active part in society. So any measure that improves mental health must help the social and economic deficits of the nation.”

Evidence of such potential savings emerged in a major study in 2012 in Massachusetts, the first US state to legalise same-sex marriage in 2003. The study looked at 1,211 gay and bisexual men attending a community health centre during the 12 months before and the 12 months after the legalisation of same-sex marriage and examined the impact on healthcare use and associated costs before and after the law changed.

It found that in the 12 months following the change, medical visits about physical health issues by this group decreased by 13 per cent and healthcare costs decreased by 10 per cent, compared with the 12 months before the change. Medical visits about mental health issues decreased by 13 per cent and associated costs by 14 per cent.

The experiences of Dublin-born psychiatrist Dr Iain Jordan, who trained at the RCSI and is now a Consultant in Psychological Medicine at Oxford University Hospital Trust, have convinced him there is a compelling case, both medical and socially, in favour of marriage equality, he tells MI.

“Epidemiological studies from the US are very compelling, as are studies that show legislation that excludes gay and lesbian people is discriminatory and falls well within the definition of stigma. Those are subtle messages that gay people receive throughout their lifetime that increase stress and lead to mental health problems and substance abuse.”

Such experiences of discrimination can be even more pernicious than more overt forms of mental or physical abuse, according to Dr Jordan. “Many of the patients we see have had experiences such as outright abuse that are risk factors for mental health difficulties in later life but actually, the commonest forms we see are more insidious — devaluation and invalidation rather than what might be termed outright abuse. And constitutionally-mandated discrimination would fall well within that definition.

Dr Paul D’Alton

“There is excellent evidence that gay men and women experience marriage bans as discriminatory and stigmatising. That is the subjective experience of these bans. So the principle of defining marriage as a legal union between a man and a woman is a form of institutional discrimination. That is not only evidence-based, it is also the position of a number of professional bodies like the American Medical Association and the American Psychological Association and the Royal College of Psychologists.

“There is also good evidence that gay marriage bans are associated with psychological morbidity. In American states, for instance, where there was gay marriage and that subsequently introduced gay marriage bans, there were longitudinal epidemiological studies that showed a rise of up to 250 per cent in psychological disorders. There were smaller rises in substance abuse and depression.”

These studies are compelling, Dr Jordan says. He emphasises that “devaluation of gay marriage at a legislative level” would most likely have similar effects, as demonstrated in such studies. It is well known, he adds, that gay men and women have high rates of psychological morbidity and a very large part of the reason is discrimination and stigma.

Dr Jordan was motivated to get involved with the newly-launched Doctors for Marriage Equality, which supports passage of the upcoming referendum, because he believes marriage equality is in the interests of public health. Doctors for Marriage Equality is made up of several hundred doctors and medical students from around the country.

Dr Jordan also tells MI that he believes there is misuse of medical studies by those against such equality. “There is a misuse of medical information and I want to present it in an accurate fashion. There is a lack of clarity and professionals and professional bodies should clear that up. It is a role of scientists to correct inaccuracies in presenting medical literature.”

He stresses that passage of the referendum would be good from a purely mental and physical health point of view. “Gay marriage bans are a form of institutional discrimination and have been shown to be associated with worse mental and physical health outcomes for gay men and women. So from the point of view of a specialist in mental and physical health, passage of the referendum would be a positive move.”

Some have suggested that gay marriage rights are unnecessary because civil partnerships have already been legalised in Ireland. But that notion is firmly rejected by Dr Paul D’Alton, Department head and Clinical Lead at the Department of Psycho-oncology at St Vincent’s University Hospital, Dublin, and President of the Psychological Society of Ireland.

“While civil partnership is to be welcomed and was a huge step forward for us socially and psychologically as a nation, what it has created is almost a two-tier system,” he tells MI. “You have some relationships that are validated through marriage and are internationally recognised. But we have created another category of civil partnership that might be looked on as a ‘second class’ of relationship.


“There are absolute distinctions drawn in terms of rights that are provided through marriage and those that are provided through civil partnership. But maybe even more important is the psychological impact of that two-tier system,” Dr D’Alton says. Stressing what he describes as the injustices inherent in a two-tier system and the psychological and emotional distress these cause, Dr D’Alton draws an analogy with the black community’s struggle for equal rights in the United States.

“It’s as if one set of relationships is inferior. It’s a bit like black people and civil rights — when black people were told they can use public transport but they must sit at the back of the bus. Well, they said, ‘actually no, we need to share this; we need to be able to sit where we wish. Segregation isn’t equality’.

“We have got to understand that marriage is a construct that naturally evolves over time. There was a time when interracial marriage wasn’t allowed, when arranged marriages were common in this country or the dowry payment system was in operation. We look back now and consider this objectionable. The evolution of marriage reflects the reality of lives and the diversity in love. So I would see marriage equality as a very natural evolution.

Emotional health

“We know from the literature that minority groups in our society fare less well in terms of emotional and psychological health so there’s a cost to that double-standard of exclusion and that’s something we really need to tackle in saying ‘yes’ to the referendum, in saying ‘yes’ to marriage equality. A lot of the inherent, perceived prejudice that gay and lesbian people experience will be softened hugely if the referendum is passed and this is likely to have a significant impact in the medium- to long-term on people’s sense of themselves as valuable and equal under our Constitution.”

Citing a large study, Supporting LGBT Lives, that was conducted in 2009 and which looked at the mental health needs of the LGBT community in Ireland, Dr D’Alton says one issue it had highlighted was the high number of participants who would not disclose their sexuality to their primary healthcare provider.

The impact of such secrecy, especially on older homosexuals who had to live for decades hidden in the dark shadows of Irish society, is something that Dr D’Alton has found especially tragic. “It is extremely sad at the end of their lives. I have worked with a number of gay people as they approach their own death and very often their distress is due to the fact that when they were growing up, homosexuality was criminalised and that had a huge impact on their ability to form significant relationships. This comes into sharp focus at the end of life, when for most people the quality of the relationships they’ve had really matter.

“So the referendum has implications. It is really a way to say very clearly to people that ‘we value and we treat your relationship as equally as the next person’s and we’re going to amend the Constitution to reflect that’. That’s a very, very powerful message and will go a long way to healing the psychological distress associated with the current situation.”

Dr D’Alton also warns against the misuse in the marriage equality debate of psychological research, particularly when related to minority or vulnerable groups in society. “Research can have far-reaching implications, especially for the many children of gay parents, and the lesbian and gay adolescents and families who are at the centre of the marriage referendum.


“Debate and conversation are absolutely essential, but psychological research must be accurately represented. The conclusions reached by representative bodies such as the APA and the PSI should be the primary reference point when discussing the psychological evidence during the marriage equality debate.”

He points out that, historically, psychological research has been used to justify the unjust treatment of minorities and said the Psychological Society of Ireland is committed to ensuring that psychological research is not used, inadvertently or otherwise, to repeat such injustices.

“The Psychological Society of Ireland is calling for those engaged in the ongoing public debate to do so with respect for the psychological and emotional impact on young people and families at the heart of the issue,” Dr D’Alton stresses.

There are subtle messages that gay people receive throughout their lifetime that increase stress and lead to mental health problems and substance abuse

Evidence pointing to the benefits to the health and wellbeing of children when same-sex parents can marry is also well documented in a number of studies. A 2013 report by The American Academy of Paediatrics, entitled Promoting the Well-Being of Children Whose Parents Are Gay or Lesbian, published in the journal Paediatrics, stated: “Extensive data available from more than 30 years of research reveal that children raised by gay and lesbian parents have demonstrated resilience with regard to social, psychological and sexual health, despite economic and legal disparities and social stigma.

“Many studies have demonstrated that children’s wellbeing is affected much more by their relationships with their parents, their parents’ sense of competence and security, and the presence of social and economic support for the family than by the gender or the sexual orientation of their parents. Lack of opportunity for same-gender couples to marry adds to families’ stress, which affects the health and welfare of all household members. Because marriage strengthens families and, in so doing, benefits children’s development, children should not be deprived of the opportunity for their parents to be married.”

The Australian Study of Child Health in Same-Sex Families (ACHESS) is the world’s largest attempt to study how children raised by same-sex couples compare to children raised by heterosexual couples.

According to a preliminary report, the study of 500 children across Australia found these young people are not only thriving, but also have higher rates of family cohesion than other families. An interim report found there was no statistical difference between children of same-sex couples and the rest of the population on indicators including self-esteem and emotional behaviour.

Same-sex parents

The researchers questioned the 500 about family cohesion, social adjustment, mental health and general physical health. They then compared the results to those representative of the entire population of Australia. The researchers found that children raised by same-sex parents scored about 6 per cent higher than those raised by opposite-sex parents, even when socio-demographic factors such as parent education and household income were kept constant. Thus, the conclusion was that children raised by same-sex parents are potentially happier and healthier than children raised by opposite-sex parents.

Another US study in July 2013 found that family type is not a predictor of a child’s psychological adjustment among early-placed adopted children with lesbian, gay or heterosexual parents. The study by the Williams Institute at the University of California was entitled ‘Predictors of Psychological Adjustment in Early Placed Adopted Children With Lesbian, Gay, and Heterosexual Parents’ and was published in the Journal of Family Psychology.

An estimated 16,000 same-sex couples are raising more than 22,000 adopted children in the US, the Williams Institute said, and these findings indicate that these children will likely fare no differently, as a result of their family type, than those being raised by heterosexual parents.

In 2001, China’s Ministry of Health officially removed homosexuality from its list of mental illnesses. The same year, the Netherlands became the first country to legalise same-sex marriage and over the next 14 years at least 18 other countries followed suit.

In his closing remarks at the IMO AGM, Minister for Health Leo Varadkar called on doctors to support the referendum and their gay and bisexual colleagues. It will become clear in May if Ireland will become the latest country to support such marriage, embracing not only the principle of equality, but also a compelling healthcare argument.

Doctors for Marriage Equality


Twitter: Follow @Dr4MEIreland;


US medical bodies back gay marriage rights

On May 9, 2012, President Barack Obama announced from the White House that he believed same-sex couples should be granted the right to marry, becoming the first US President to do so. Almost exactly two months later, on July 10, 2012, a number of America’s leading medical organisations came together to file an amicus brief in support of a California gay marriage rights case.

The groups were the American Medical Association, the American Psychological Association, the California Psychological Association, the American Psychiatric Association, the National Association of Social Workers, the American Academy of Paediatrics and the American Psychoanalytic Association. They set out their case to the court and the country as follows:

“The American Psychological Association, the world’s largest professional association of psychologists, is a scientific and educational organisation dedicated to increasing and disseminating psychological knowledge. The Association has adopted multiple research-based policy statements supporting the rights of gay and lesbian people, including a 2011 policy statement supporting full marriage equality and calling on the federal government to extend full recognition to legally-married same-sex couples, and to accord them all of the rights, benefits and responsibilities that it provides to legally-married, different-sex couples.”

‘The California Psychological Association is the nation’s largest state psychological association, representing all areas of psychology. The American Psychiatric Association is the Nation’s largest organisation of physicians specialising in psychiatry. It joins this brief for the reasons expressed in its 2005 position statement, ‘Support of Legal Recognition of Same-Sex Civil Marriage’. The American Psychiatric Association supports the legal recognition of same-sex marriage with all rights, benefits and responsibilities conferred by civil marriage, and opposes restrictions to those same rights, benefits and responsibilities.”

“The National Association of Social Workers (NASW) is the largest association of professional social workers in the world. NASW develops policy statements on issues of importance to the social work profession and, consistent with those statements, NASW and its California Chapter (also an amicus herein) support full social and legal acceptance of lesbian, gay, and bisexual people.”

“The American Medical Association (AMA) is the largest professional association of physicians, residents and medical students in the United States, substantially all of whom are represented in the AMA’s policy-making process. The objectives of the AMA are to promote the science and art of medicine and the betterment of public health. Its policies regarding gay and lesbian issues promote those objectives.”

“The American Academy of Paediatrics (AAP) is the largest professional association of paediatricians in the world, with over 62,000 members. Through education, research, advocacy, and the provision of expert advice, AAP seeks the optimal physical, mental and social health and wellbeing for infants, children, adolescents and young adults.”

“The American Psychoanalytic Association is the oldest and largest national psychoanalytic membership organisation, with more than 3,500 members and associates. It believes that marriage is a basic human right and that same-gender couples should be able to share equally in the rights and responsibilities of civil marriage.”

Today, same-sex couples can legally marry in 37 of the 50 US states.

Countries where same-sex couples can marry

  • The Netherlands (2001)
  • Belgium (2003)
  • Canada, Spain (2005)
  • South Africa (2006)
  • Norway, Sweden (2009)
  • Argentina, Portugal, Iceland (2010)
  • Denmark (2012)
  • Brazil, France, Uruguay, New Zealand (2013)
  • United States: Same-sex couples can legally marry in 37 of the 50 US states.
  • England, Scotland, Wales, Luxembourg (2014)
  • Finland (2015)

  1. Odhrán Allen on May 4, 2015 at 12:04 am

    Great article Bette. Very comprehensive overview of the evidence on LGBT mental health and emotional wellbeing and the ill-effects of social exclusion on these. No doubt the benefits of marriage equality extend beyond parity of legal and constitutional status and protection to increased social capital and improved health outcomes among LGBT people. In an Irish context three professional bodies have so far adopted a position in support of marriage equality and a Yes vote in the referendum on May 22nd – the Psychological Society of Ireland, the Irish Association of Social Workers and the Irish Institute of Mental Health Nursing

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