The debate over same-sex marriage – or “gay marriage” – has been contentious in national and state politics for nearly twenty years. After voters in many states rushed to ban same-sex unions, the tide turned. In recent years, sixteen states and the District of Columbia have legalized same-sex marriage and another three states have approved civil unions or domestic partnerships that include full spousal rights for lesbian, gay and bisexual couples. Despite this progress, as of the end of 2013, only 37% of Americans live in a state with marriage equality; and many lesbian, gay, and bisexual people still do not enjoy the full rights and benefits associated with marriage. This is unfortunate for moral and economic reasons. Equally important, a growing body of public health research documents the many health benefits associated with legal same-sex marriage.

Harm from Discrimination and Marriage Bans

Numerous health studies conducted during the past decade have documented how discrimination causes harm and leads to significant health disparities. Discriminatory environments and public policies create public stigma and can provoke feelings of rejection, shame and low self-esteem. Limiting marriage to heterosexual couples denies lesbian, gay, and bisexual adults access to an important social institution and in an important sense turns them into second-class citizens.Limiting marriage to heterosexual couples denies lesbian, gay, and bisexual adults access to an important social institution and in an important sense turns them into second-class citizens.

Denying legal recognition to gay partnerships also reduces access to affordable health insurance. Most Americans, some 55%, are covered through their own or a family member’s employer-sponsored health insurance plan. But many employers do not extend coverage to same-sex partners or children of same-sex partners. Even among large companies with more than 500 employees, only half offer health benefits to same-sex partners. When states adopt legal same-sex marriage or legalize civil unions, many workplaces offering health insurance are required to treat married same-sex couples like married heterosexual couples. But most states still discriminate, and several research studies have reported related disparities in health and access to care for lesbians, gays, 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 states with same-sex marriage to report symptoms of depression, anxiety, and alcohol use disorder.
• Same-sex couples across the country are less likely to have health insurance and are more likely to delay or forgo medical care.

Same-Sex Marriage Improves Health and Access to Health Care

Research on marriage and health reports a consistent and well-established theme: married people live happier, healthier and longer lives. Consequently, expanding and supporting marriage for same-sex couples should enable lesbian, gay, and bisexual adults to live happier, healthier and longer lives. In fact, studies conducted in states that have adopted same-sex marriage have already established significant improvements in health and access to care:

• A study in Massachusetts followed a group of gay and bisexual men before and after the legalization of same-sex marriage and discovered that these men became less likely to need mental health or medical care visits.
• Two studies found that lesbian, gay, and bisexual adults who married following the California Supreme Court ruling in favor of same-sex marriage reported less psychological distress and were more likely to gain health insurance coverage.

The health benefits from legal same-sex marriage extend beyond the adults themselves – particularly to the 220,000 children in the United States being raised by same-sex parents. Employers who offer health insurance to dependent children often require minors to be related to the employee by birth, legal marriage or legal adoption. Thus, children are left with diminished protections in states that do not allow legal marriages or adoptions for lesbian and gay couples.

A study recently reported in Pediatrics found that children with same-sex parents were less likely to have private health insurance than children with heterosexual parents. The study also found that disparities in private insurance coverage diminished for children of same-sex parents living in states with marriage equality or laws supporting gay and lesbian adoptions.

How All States Can Improve Family Protections

Given political gridlock in Congress, states are more likely than the federal government to advance protections for members of gay, lesbian, and bisexual families. Public opinion is shifting rapidly in support of same-sex marriage, so more states will take this step. But not all states will legalize same-sex marriage in the immediate future, and in many of these lagging states, steps forward will take the form of measures that garner stronger public support than legal marriage. Such steps beneficial to the lesbian, gay, and bisexual population include anti-discrimination laws in housing and employment; rights of legal adoption by gay and lesbian couples; anti-bullying laws to better protect gay youth from harassment; and inclusion of crimes against gays, lesbians, and bisexual people in anti-crime legislation. Each of these steps can reduce discrimination and lead to improvements in mental and physical health.

The path towards same-sex marriage may follow two steps in more conservative states or states controlled by Republican lawmakers and administrations. Initially, states may adopt civil unions or comprehensive domestic partnerships that include full spousal rights and protections for members of gay and lesbian partnerships – to be followed later by full marriage equality by legislation or court rulings. This staged approach has happened in several states, most recently in New Jersey and Colorado.

Regardless of which path states follow toward equality, the health benefits associated with same-sex marriage cannot be overlooked. These benefits should always be highlighted as debates continue in legislative chambers, election contests, and federal and state courtrooms.