While the ban on same-sex marriage is hotly debated between conservative groups and lesbians and gay men, several psychiatrists are researching and discussing how denial of same-sex marriage impacts mental health.
August 2006, Vol. XXIII, No. 9
As conservative groups push for a constitutional amendment that defines marriage as a union between a man and woman1 and lesbians and gay men initiate lawsuits to overturn state bans against same-sex marriages,2 several psychiatrists are researching and discussing how denial of same-sex marriage impacts mental health.
At the American Psychiatric Association (APA) meeting in Toronto, Gene Nakajima, MD, staff psychiatrist with San Francisco's Center for Special Problems, and Mary E. Read, MD, assistant clinical professor in the department of psychiatry at Harbor-UCLA Medical Center, co-chaired a symposium on same-sex civil marriage.
One presenter was Ellen Haller, MD, adjunct professor of psychiatry at the University of California at San Francisco, who described her own experience. When same-sex marriages became legal in San Francisco in 2004, Haller and her partner of 18 years, together with 2 gay men who had been a couple for 20 years, quickly arranged for a civil ceremony at city hall. Together, the couples were co-parenting their 7-year-old son, Danny. For the ceremony, the couples were going to take turns saying their vows in front of close family and friends. Danny was going to recite a poem he had written about love and play a song on the violin. Afterward, a dinner reception was planned.
Although Haller and her partner had already registered as domestic partners with the state, they wanted to get married for several reasons.
One [reason] was to bring visibility to the lack of equal civil rights historically for gay and lesbian couples, another was to publicly affirm our love and commitment for each other in front of friends and family, and a third was to take part in an exciting and wondrous time in San Francisco, Haller told Psychiatric Times.
But their marriage was not to be. On March 11, 2004, 4 days before the planned marriage, the California Supreme Court ruled that San Francisco had to cease and desist the granting of same-sex marriage licenses. So instead of a marriage ceremony, the couples found themselves participating in a protest march. Danny, who chose to participate in the march, confided to a television reporter that he was angry at a government that wouldn't allow his moms and dads to get married and that he didn't understand why.
Asked about the mental health effects of the ban, Haller said, Being treated as a second-class citizen conveys the message that one is less worthy than others. Lack of equal civil rights can degrade people's self-esteem and can ultimately lead to a sense of negative self-worth, and possibly depression and substance abuse.
A strong link exists between discrimination and psychological distress, according to Robert Kertzner, MD, and Gilbert Herdt, MD, who recently published an article on the topic in the journal Sexuality Research & Social Policy.3 Their research, supported by the Evelyn and Walter Haas Jr. Fund, was an analysis of 150 studies and articles published during the past 30 years on marriage, discrimination, and denial of marriage to same-sex couples.
Kertzner, associate clinical professor of psychiatry at the University of California at San Francisco and adjunct associate research scientist in the department of psychiatry at Columbia University in New York, also spoke at the APA symposium.
Many researchers, he said, have studied the effects of discrimination on mental health, both in the general population and among lesbians and gay men.4,5
These studies have shown that the experience of discrimination is associated with increased psychological distress and increased rates of psychiatric morbidity, such as increased rates of depression and anxiety, Kertzner told Psychiatric Times.
One study by Mays and Cochran4 looked at a nationally representative sample of adults aged 25 to 74 years and self-identifed as homosexual or bisexual (n = 73) or heterosexual (n = 2844). The researchers concluded that higher levels of discrimination may underlie recent observations of greater risk of psychiatric morbidity among lesbian, gay, and bisexual individuals.
Both the American Psychological Association6 and the APA,7 Kertzner said, have issued statements in favor of marriage equality for lesbians and gay men, citing the harmful effects of discrimination on mental health.
Because nearly all states deny the right to civil marriage, with the exception of Massachusetts, the APA said, Same-sex couples are currently denied the important legal benefits, rights, and responsibilities of civil marriage. Same-sex couples therefore experience several kinds of state-sanctioned discrimination that can adversely affect the stability of their relationships and their mental health.
Kertzner said that stigmatization of homosexuality is perpetuated by discrimination in marriage denial and that, in turn, perpetuates a vicious circle. Because they are not being allowed to marry, same-sex couples often experience commitment ambiguity marked by uncertainty about the extent of mutual obligations in the relationship ; uncertainty about the recognition of the partnership by family, friends, and others; and uncertainty about when the relationship is over. That ambiguity serves to support stereotypes that lesbians and gay men are incapable of staying together and are therefore unworthy of being married and should be denied marriage.
Marriage denial to same-sex couples in the United States has been based, in part, on assumptions about the immorality and sexual promiscuity of gay men and lesbians.8
Yet Herdt and Kertzner,3 in their article, cite numerous studies that show that a significant number of lesbians and gay men form committed long-term relationships that provide stability, support, increased life satisfaction, and an enhanced sense of personal meaning over the lifespan.
Beyond discrimination being associated with increased psychiatric distress, Kertzner said there are other adverse effects associated with not being able to marry.
They would include the following: All relationships benefit from social support and legal recognition, and that is true for lesbians and gay men as well as for heterosexuals. Without the very specific legal recognition of being married, on a very concrete level, many lesbians and gay men are denied financial advantages that accrue to married couples and a variety of benefits associated with survivorship when one partner dies, he said.
One population most affected by the lack of marital rights and protections is older lesbians and gay men, said Kertzner. Institutional benefits to married couples include spousal benefits, such as Social Security and public pensions; income tax benefits; inheritance, insurance, and survivorship rights (including estate tax benefits); and the power to make medical decisions on behalf of a spouse.3 Most same-sex couples do not have these rights.
From an anthropologic and historical viewpoint, Kertzner noted that in most cultures being married is the only way to legitimize one's sexuality.
So if you can't be married, there is no legitimization of one's sexuality, which, in turn, creates problems for lesbians and gay men with respect to stigma, self-acceptance, and lack of support from family and communities, he said.
In addition, in most societies, marriage is considered the key to being regarded as a full adult, Kertzner continued. By being denied the opportunities of marriage, lesbians and gay men are also denied the opportunity to be seen as full citizens and full adults participating in society.
The bans on same-sex marriages also affect the children of lesbians and gay men, according to Kertzner.
Marriage provides much more stability and structure for parents raising children, it protects the rights of nonbiologic parents, it provides a process for the legal resolution of custody issues, and it provides a sense of psychological stability for children being raised by gay and lesbian parents, he said. Estimates are that there are several million children being raised by gay and lesbian parents in the United States. And although the studies show that they are no different from children being raised by heterosexual parents with respect to school adjustment and psychological health,9,10 children being raised by gay and lesbian parents nonetheless do have to contend with [the] stigma of having unmarried parents and some of the legal uncertainties about what would happen to them if something happened to their biologic parent.
Among the issues explored at the APA symposium was whether lesbians and gay men even want to get married. Data from the Kaiser Family Foundation showed that 74% of lesbians, gay men, and bisexuals want to get legally married.11 Kertzner told Psychiatric Times that across studies, 40% to 70% of gay men and 45% to 85% of lesbians report currently being involved in a committed relationship.
While Massachusetts is the only state to grant lesbians and gay men the legal right to marry, several countries-- including the Netherlands, Belgium, Spain, Canada, and more recently the Republic of South Africa--have passed laws to affirm marital and parental rights for same-sex couples. More than 10,000 gay and lesbian couples have married in Canada since mid-2003, according to Canadians for Equal Marriage. In the Netherlands, some 8100 couples have married since civil marriage became open to same-sex couples in 2001, said Nicolaas Hettinga, MD, a presenter at the APA same-sex marriage symposium.
In these 5 years, the number of divorces is similar to that of heterosexuals, Hettinga added.
Unlike Belgium and the Netherlands, Canada does not have any residency requirements for marriage, so many US citizens have traveled there to be wed. Nakajima noted at the APA symposium that he and his partner went to British Columbia in 2003 to be married.
Kertzner, who maintains a private practice in San Francisco with a focus on promoting psychological well-being among lesbians and gay men, said he has worked with several same-sex couples who were married in Canada, and marriage has been a remarkable experience for them.
The one word that they all use in describing their experience in getting married legally is 'surprise,' that is to say, they just didn't know how transforming an experience this would be for them, Kertzner said. A case in point: I worked with a man who was in a long-term relationship and got married in Canada about a year ago. He described what it was like for his family to come together and meet his partner's family, and he [asked the question] . . . 'short of a marriage, when do family members of both partners really have an opportunity to meet each other?'
Because same-sex marriages are a recent phenomenon, Kertzner said he had not yet found any studies looking at the mental health effects of samesex marriages. He posited at least 2 possible effects of such marriages.
Numerous studies exploring the relationship between mental health and marriage in the general population have suggested that on average, married individuals have better mental health, more emotional support, less psychological distress, and lower rates of psychiatric disorder than do the unmarried. He expected that many, if not most, of the benefits of marriage also would be applicable to lesbians and gay men.
A second effect, he said, was that simply giving the people the choice or option of getting married, whether or not they exercise it, may also have positive mental health effects on lesbians and gay men.
Opponents of legalizing same-sex marriage have predicted dire effects on the general population. There are 2 findings relevant to this point, according to Kertzner. One is that over time in the United States, there has been a gradual decrease in the percentage of Americans who are strongly opposed to same-sex marriage, and a gradual increase in the number who support it. A Gallup Poll this past May found the public almost evenly divided over a constitutional amendment banning same-sex marriage, with 50% in favor and 47% opposed,1 and if you look at young adults between the ages of 18 and 30, Kertzner added, 51% supported legalizing gay marriage.
Second, with respect to arguments about the potential negative social effects of allowing gay men and lesbians to marry, Kertzner pointed to the work of M. V. Lee Badgett, PhD, an associate professor of economics at the University of Massachusetts Amherst. In a briefing paper prepared for the Council on Contemporary Families and the Institute for Gay and Lesbian Strategic Studies, Badgett presented evidence showing that adoption of same-sex marriage and same-sex partnership rights in Scandinavia and the Netherlands had not changed previously existing trends in marriage, divorce, cohabitation or out-of-wedlock childbearing and had not undermined heterosexual marriages.12
1. Means M. Nation more accepting of gay marriage. Seattle Post-Intelligencer. 2006. Available at: http://seattlepi.nwsource.com/opinion/273078_ means08.html. Accessed June 29, 2006.
2. Associated Press. Where gay marriage cases stand in state courts. The Mercury News. 2006. Available at: http://www.mercurynews.com/mld/mercurynews/news/local/states/california/northern_california/14784335.htm. Accessed June 29, 2006.
3. Herdt G, Kertzner RM. I do, but I can't: the impact of marriage denial on the mental health and sexual citizenship of lesbians and gay men in the United States. Sex Res Soc Policy. 2006:3(1):33-49.
4. Mays VM, Cochran SD. Mental health correlates of perceived discrimination among lesbian, gay, and bisexual adults in the United States. Am J Public Health. 2001;91:1869-1876.
5. Ryff CD, Keyes CL, Hughes DL. Status inequalities, perceived discrimination, and eudaimonic wellbeing: do the challenges of minority life hone purpose and growth? J Health Soc Behav. 2003;44:275-291.
6. American Psychological Association Council of Representatives. Resolution on sexual orientation and marriage. Available at: http://www.apa.org/pi/lgbc/policy/marriage.pdf. Accessed June 29, 2006.
7. American Psychiatric Association. Support of legal recognition of same-sex civil marriage: position statement. Available at: http://www.psych.org/edu/other_res/lib_archives/archives/200502.pdf. Accessed June 29, 2006.
8. Jordan MD. Blessing Same-Sex Unions: The Perils of Queer Romance and the Confusions of Christian Marriage. Chicago: University of Chicago Press; 2005.
9. Golombok S, Perry B, Burston A, et al. Children with lesbian parents: a community study. Dev Psychol. 2003;39:20-33.
10. Wainright JL, Russell ST, Patterson CJ. Psychosocial adjustment, school outcomes, and romantic relationships of adolescents with samesex parents. Child Dev. 2004;75:1886-1898.
11. Kaiser Family Foundation. Inside-OUT: a report on the experiences of lesbians, gays and bisexuals in America and the public's views on issues and policies related to sexual orientation. 2001. Available at: http://www.kff.org/kaiserpolls/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=13873. Accessed June 29, 2006.
12. Council on Contemporary Families. Same-sex marriage does not influence heterosexual marriage, says report for Council on Contemporary Families. Available at: http://www.contemporaryfamilies.org/subtemplate.php?t=pressReleases&ext=July13-. Accessed June 29, 2006.