Denial of services to same-sex couples can harm their health

In the Supreme Court hearing for Masterpiece Cakeshop v. Colorado Civil Rights Commission, lawyers for the baker argued that he should not have to sell a cake to a same-sex couple because his religion does not support same-sex marriage.

Debates around this case have referenced potential implications for the dignity of sexual minority populations, but in the absence of data to ground the conversation.

{mosads}In a new study published in JAMA Psychiatry, we found that state laws permitting the denial of services to same-sex couples are associated with a 46 percent increase in mental distress among gay, lesbian, and bisexual adults.

The study sheds light on how the denial of services to same-sex couples — such as decorating a wedding cake, in the case currently before the Supreme Court — can harm health.

Our study takes advantage of a natural experiment created by implementation of laws permitting the denial of services to same-sex couples in some states and not in similar, nearby states. Gay, lesbian, and bisexual adults reported greater levels of mental distress at the beginning of the study in 2014, with 23.0 percent of those in the sample reporting mental distress, relative to 12.5 percent of heterosexual adults.

In states that implemented policies permitting the denial of services to same-sex couples in 2015, mental distress among gay, lesbian, and bisexual adults increased from 21.9 percent to 32.8 percent, a 10.9 percentage point increase from 2014 to 2016. In contrast, mental distress increased just 0.8 percentage points among heterosexual adults in the same states and by 1.3 percentage points for gay, lesbian, and bisexual adults in control states during the same time period.

In the final analysis, laws permitting the denial of services to same sex couples were associated with a 46 percent relative increase in mental distress among gay, lesbian, and bisexual adults compared to other groups.

This is in no way hard to believe or far-fetched.

Policies that deny services may directly affect the mental health of those denied services and others in their social networks. Indeed, the mother of Charlie Craig, a respondent in the Masterpiece Cakeshopcase, has described the trauma of watching her son transform from delight to devastation the day he and his husband were denied a wedding cake.

While relatively few same-sex couples were likely turned away from marriage licenses or adoptions within the 7 to 18-month period following policy implementation, policies permitting the denial of services to same-sex couples signal to all that members of this minority group are not equal people deserving of equal dignity. Our data suggest permitting the denial of services to same-sex couples is harmful in ways well beyond the denial of service itself.

This issue is not an esoteric problem linked to cake, unfortunately. Twelve states currently have policies permitting the denial of services to lesbian, gay, bisexual, or transgender (LGBT) individuals based on religion. In Kentucky and Kansas, schools can bar LGBT students from participating in student groups. In Tennessee, mental healthcare counselors can turn away LGBT patients. In Mississippi, there is broad license to turn away LGBT individuals from public accommodations, and a funeral parlor recently refused a grieving man’s request to cremate his deceased husband.

Momentum to further deny services to particular populations is growing. At the federal level, Senator Mike Lee recently introduc­­­ed the so-called First Amendment Defense Act to permit people to deny services to LGBT individuals across the country. The Department of Health and Human Services has a new Conscience and Religious Freedom Division that may promote widespread discrimination against LGBT individuals by healthcare providers. Last week, the Williams Institute reported that the Centers for Disease Control and Prevention will discontinue collecting the sexual orientation data that we used to conduct our study. 

The Supreme Court decision in the Masterpiece Cakeshop case will undoubtedly have broad implications for federal, state, and local laws governing LGBT discrimination. Our research suggests that a decision granting legal permission to deny services to same-sex couples would have a profound effect on the mental health of our gay, lesbian, and bisexual citizens. The Supreme Court justices and judges and policymakers across the country may wish to carefully consider the mental health harm caused by denying services — wedding cakes or otherwise — to gay, lesbian, and bisexual populations.

Julia Raifman, ScD, is an assistant professor in the Health Law, Policy & Management Department at the Boston University School of Public Health. Sandro Galea, MD, DrPH, is Dean and Robert A. Knox professor at the Boston University School of Public Health.