Feature

A year and a half ago when Washington state legalized same-sex marriage, Seattle clinical psychologist Laura Brown, PhD, and her long-term partner, Lynn, cheered. Domestic partners since 2007, the couple never thought they'd have the option to marry, and they plan to wed in June, on the 15th anniversary of the day they met.

"I'm 61 and my fiancée is 60, and initially we thought it was mostly a financial decision for us, so that when one person dies the surviving spouse won't have to deal with estate taxes," Brown says. "But the more we talked about it with each other and with friends, we realized that being able to marry really feels different, even for people who have been together 20 or 30 years."

That reality has been hitting an increasing number of couples across the country. From California to Rhode Island, 2013 was a landmark year for marriage equality in the United States. Before last year, same-sex marriage was legal in just eight states and the District of Columbia. But last June, the U.S. Supreme Court ruled in U.S. v. Windsor that the federal government must recognize same-sex marriages performed in states where such marriages are legal. Since then, nine more states have legalized same-sex marriage. And in a major milestone for gay rights, the federal government expanded its recognition of same-sex marriages in federal legal matters, including bankruptcies, prison visits and survivor benefits, even in states where same-sex marriage is not legal.

These steps toward marriage equality are a triumph for social science, and will likely enhance well-being among lesbian, gay and bisexual (LGB) individuals nationwide — though particularly in the states that have legalized same-sex marriage, says Glenda Russell, PhD, a Colorado clinical psychologist and author of the 2000 book "Voted Out: Psychological Consequences of Antigay Politics."

"There's a fair amount of accumulating evidence that says when people are in places where they have more rights as opposed to fewer rights, mental health is advantaged by that," Russell says.

With those rights, however, come some new stressors, including a new level of exposure as an LGB individual, and perhaps additional pressure from family, friends — and even society — for couples to marry.

"These are good problems to have, given that we're talking about an accumulation of rights and the opportunity to do things differently, but I think they're also problems that carry some stress and decision-making and some pressure to conform that haven't been there in the past," Russell says. "That's a demand on people's energy and time and interpersonal problem solving."

What the research shows

While the latest legislative victories may be too new for investigators to examine their effects, prior research suggests that policy changes or community attitudes for or against same-sex marriage can strongly influence patterns of health care — and even mortality rates — for LGB people.

In a 2010 study led by Columbia University psychologist Mark Hatzenbuehler, PhD, researchers examined the mental health of LGB people at two moments in time: before their states voted for constitutional amendments to ban same-sex marriage and after the amendments went into effect.

Hatzenbuehler and his colleagues found that LGB individuals in states that enacted the amendments experienced a significant increase in psychological and behavioral disorders, compared with those LGB individuals in states without such amendments. Specifically, the study found a 37 percent increase in mood disorders such as depression, a 42 percent increase in alcohol use disorders, and quite strikingly, a two-fold increase in generalized anxiety disorder in the 12 months following the bans (American Journal of Public Health, 2010).

The study also showed that rates of psychological and behavioral disorders didn't increase among LGB adults in states without constitutional amendments and that there were few changes in these disorders among heterosexuals in the states that banned same-sex marriage.

"We're really finding specificity of the effect of these policies to LGB individuals who lived in states passing those same-sex marriage bans, suggesting that these bans were harmful for mental health," Hatzenbuehler says.

A study published in February suggests even broader consequences of prejudice against the LGB community: Hatzenbuehler and his team found that LGB individuals who lived in communities with high levels of anti-gay prejudice have a life expectancy 12 years shorter on average compared with their peers in the least prejudiced communities (Social Science & Medicine).

In the study, researchers constructed a measure capturing the average level of anti-gay prejudice in communities using data on prejudicial attitudes from the General Social Survey, conducted by the National Opinion Research Center since 1972 and often considered one of the primary sources of social indicator data. The researchers then linked the information on sexual orientation and community-level prejudice to mortality data via the National Death Index, from 1988 through 2008. By the end of the study, 92 percent of LGB respondents in low-prejudice communities were still alive, compared to only 78 percent of the LGB respondents living in high-prejudice communities. The researchers also found that suicide, homicide and cardiovascular diseases were all substantially elevated among sexual minorities in high-prejudice communities. For instance, LGB respondents living in high-prejudice communities died of suicide on average at age 37.5 compared with age 55.7 for those living in low-prejudice communities.

In addition, of the deaths in high-prejudice communities, 25 percent were due to cardiovascular disease, compared with 18.6 percent of deaths in the low-prejudice communities.

"Psychosocial stressors are strongly linked to cardiovascular risk, and this kind of stress may represent an indirect pathway through which prejudice contributes to mortality," Hatzenbuehler says. "Discrimination, prejudice and social marginalization create several unique demands on stigmatized individuals that are stress-inducing."

A heartening trend in light of recent same-sex marriage legislation, however, is that the opposite also seems to be true: In a 2012 study with more than 1,200 gay and bisexual men in Massachusetts, Hatzenbuehler found that legislation allowing same-sex marriage may have a protective effect on the physical and mental health of LGB individuals (American Journal of Public Health, 2012). Researchers followed participants for 12 months before and 12 months after the state's legalization of same-sex marriage, and found a 13 percent reduction in health-care visits and a 14 percent reduction in health-care costs.

The researchers also had access to medical billing records, allowing them to analyze the diagnostic codes physicians used to bill for participants' visits, Hatzenbuehler says. That revealed a reduction in hypertension, depression, adjustment disorders and other conditions associated with stress, he says.

"That result really suggested to us that these same-sex marriage legalizations may be improving the social environment surrounding gays and lesbians by reducing the amount of stigma-related stressors that they experience," Hatzenbuehler says.

The pressure's on

Years of evidence have shown that the psychological and social aspects of committed relationships between same-sex couples largely resemble those of heterosexual partners. Whether straight or gay, couples form deep emotional attachments and commitments and face similar issues concerning intimacy, love, loyalty and stability (Journal of Family Psychology, 2008). Empirical research also shows that lesbian and gay couples have levels of relationship satisfaction similar to or higher than those of heterosexual couples (Developmental Psychology, 2008). But, psychologists point out, marriage comes with stressors.

"For people who do have access to marriage, it can be a really good thing," Russell says. "But same-sex couples are also now having to deal with a new pressure in their relationship — put on them by themselves and by friends and family — to make decisions about their relationship that weren't in the province of couples to make in the past."

For many same-sex couples, the decision isn't really a decision at all: Brown and her partner, for example, are ecstatic to marry finally, and to enjoy the economic and social support benefits that such a union bestows. For some couples, however — particularly those in which one or both individuals may not be as open about their sexuality at work or with family — the decision to marry may require more deliberation, says Clinton Anderson, PhD, director of APA's Office on Lesbian, Gay, Bisexual and Transgender Concerns.

"Marriage is an important step and a perceived commitment that affects one's individual freedom," he says. "It also sets up ways in which one will lose the chance to remain closeted when that feels safer than being out."

The status of people's relationships becomes easily searchable in public records for having taken out a marriage license and that can create an external forcing of the issue, Russell says.

"For some couples, there are just more things to consider — for example, getting married could protect the kids, but it also might out them at work and put them in a vulnerable position" at work or with neighbors, she says.

Even those who do choose to marry may face new challenges in their relationships. For example, if one individual is offered a new job opportunity in a state that doesn't allow same-sex marriage, a move could benefit their family financially but could also negate access to protections their marriage had offered. Add children to the equation, and decisions become even more complex.

"They might have to go through the whole rigmarole of having to figure out how they are going to protect their family in a new state," Russell says. "The great job and money might be really nice, but their second-parent adoption might not be recognized in that other state."

Beyond those concerns, some LGB couples just may not be psychologically prepared for the possibility of marriage, says Minnesota counseling psychologist Marge Charmoli, PhD. Her state went from considering a ban on same-sex marriage in 2012 to legalizing it in 2013.

"When the day suddenly arrived as it did in Minnesota, same-sex couples weren't prepared for all of what that meant, because they hadn't thought about it," Charmoli says. "So now what do they do? Do they have a conventional wedding? Do they write their own rules?"

One of her clients who had been in a long-term relationship and had children with her partner wanted to marry for the legal protection, Charmoli recalls. The client's angst was palpable. "She was so anxious — mainly about little things like what to wear to the ceremony, where to have it. … I remember her saying, ‘It was never in my best interest to imagine that same-sex marriage could ever be possible.'" Other clients have found that family and friends seem more excited about their ability to wed than they are themselves.

"We are encountering friends — some our age and some a lot younger — who are getting pressured to marry," Brown says. These couples may feel stress to pick a date and plan the wedding, while they are still getting adjusted to the idea that same-sex marriage is legal.

"Parents are asking, ‘When are you two going to get married?' and ‘When are we going to have grandchildren?'" Russell says. "It's the same kinds of pressures other-sex couples have been facing forever, suddenly coming into the lives of same-sex couples in a way that hadn't been there before. It's a change for the good, but that still means that some adaptations need to be made."

Amy Novotney is a writer in Chicago.

Further references

  • Balsam, K., Beauchaine, T, Rothblum, E., & Solomon, S. (2008). Three-year follow-up of same-sex couples who had civil unions in Vermont, same-sex couples not in civil unions, and heterosexual married couples. Developmental Psychology, 44(1), 102–116.
  • Kurdek, L. (2005). What do we know about gay and lesbian couples?Current Directions in Psychological Science, 14(5), 251–254.
  • Kurdek, L. (2008). Change in relationship quality for partners from lesbian, gay male, and heterosexual couples.Journal of Family Psychology, 22(5), 701–711.