Obama, Marriage Equality, and the Health of Gay Men

As a young gay man in my early 20s witnessing the devastation of the AIDS epidemic in my community, I noted to a friend one night, “If gay men were allowed to get married, this disease would go away.” At the time, this statement was one that resonated with me, although I could not effectively articulate why I was convinced of the proposition. In fact, only recently have I come to truly understand the truth and power of my words, and how the AIDS crisis and the other numerous health disparities experienced by gay men¹ may, in fact, be ameliorated or possibly eliminated through the enactment of marriage equality.

RECENT ADVANCES

Monumental steps have been taken toward marriage equality in the United States during these last few years—historical events of which I could only dream and hope as that young gay man. In June 2011, the state of New York, my home state, passed a marriage equality law, making it the largest state in the union to enact such legislation. Shortly thereafter, Maryland and Washington followed suit, resulting in a total of seven states, in addition to the District of Columbia, that recognize this civil right of gay men to marry those whom they love. Once again, and as it has done for decades, New York served as a model of civil liberties for the entire nation as noted in the recent events on the national stage.

Within one year, the fight for marriage equality took a quantum leap forward on the federal level when Vice President Joe Biden, Secretary of Education Arnie Duncan, and, above all, President Barack Obama verbally, openly, and with conviction stated their support for marriage equality, leading journalist Andrew Sullivan to describe Barack Obama, in his Newsweek article, as “the first gay president.”² The icing on the cake came within weeks of those statements when the 1st US Circuit Court of Appeals in Boston ruled that the Defense of Marriage Act was unconstitutional, setting up an inevitable challenge in the Supreme Court, which in my heart I believe will uphold this appellate court decision.

MARRIAGE EQUALITY IS A STRUCTURAL DETERMINANT OF HEALTH

I came of age in the early 1980s, a decade after the Stonewall Riots and ensuing gay rights movement, which ensured that I could live my life openly in New York City. I am also a man approaching middle age who has seen the AIDS epidemic take its toll on those closest to me and to the gay population at large, and to some extent derail our movement toward civil rights. Despite the enormous damage, devastation, and loss I have witnessed over the last 30 years, I find myself with a renewed hope and optimism that the social and emotional lives and the physical and mental health of gay men can now only improve in light of these incredible strides toward marriage equality in the United States.

President Obama's support of marriage equality not only helps to advance the civil rights of gay men, but in the long term, will improve the health of our population. For all gay men, whether we choose to marry or not, the movement toward marriage equality and the enactment of this right in states supporting this civil liberty are structural changes—they are changes on a macro level in our society and policy, which help to enhance our social resources and strengthen our social capital.

It is this improvement in social capital that will ultimately improve our collective health, helping both ourselves and our society at large to more effectively address the physical and mental health challenges that we face. This is why I also believe that marriage equality will help to reduce the burden of AIDS for future generations of gay men. Marriage will prove to be as powerful a weapon in the prevention of this disease and should garner as much excitement as the new wave in biomedical approaches to HIV prevention, including preexposure prophylaxis (i.e., PrEP),³ which while powerful tools, falsely and dangerously have been heralded as the antidote to the AIDS crisis for the gay population.

The field of Public Health has been at the forefront for decades in delineating how health conditions and health disparities lodged in populations, such as that of gay men, are directed and exacerbated by social drivers. Like many other health conditions in the United States that presently burden our lives, HIV/AIDS is more than simply a biomedical condition. HIV is rather a disease that is better understood using a biopsychosocial framework, which helps to explain why the disease manifests in populations that are marginalized and victimized, in populations with fewer means and access, and in populations with lower levels of social capital. Said differently, discrimination and homophobia continue to fuel the HIV epidemic in gay men.⁴ As such, an antiretroviral medication cannot eradicate these factors. However, a movement toward greater equality, vis-a-vis the ability to marry, will promote the civil rights and liberties of gay men and can effectively eradicate the social determinants of HIV disease. For these reasons, all HIV prevention efforts must effectively combine the best of behavioral and biomedical technologies as recently advanced in a resolution of the American Psychological Association,⁵ and attending to these social conditions is critical to addressing all health burdens faced by gay men, beyond just HIV. Moreover, this approach aligns with the ideals of social justice espoused by pubic health researchers and practitioners.

The health disparities experienced by gay men are abundantly documented. Most estimates suggest that only two to five percent of men are sexual minorities, yet gay men represent more than 50% of all AIDS deaths and more than 50% of all and new infections.⁶ Close to 600 000 of us have died an AIDS-related death. As recently reported by the Institute of Medicine,¹ gay men, and lesbian, gay, and bisexual (LGB) individuals more broadly, also experience other health disparities compared with their heterosexual peers: in adolescence, gay men experience higher rates of suicidal ideation and depression, and in adulthood, gay men demonstrate higher rates of tobacco, alcohol, and other drug use, as well as increased mood and anxiety disorders.

These health conditions do not develop in a vacuum. They are health burdens driven by the social conditions experienced by gay men. These health problems are, in effect, caused by the hateful words of entertainment figures and the foolish and deadly acts of college students; they are perpetuated by the intolerance of the 60% or more of North Carolinians who denied their gay citizens the right to marry, and they are fueled by overly ambitious politicians pandering to voters by emphatically stating that marriage is an institution reserved for one man and one woman. These individuals are as much responsible for the ongoing AIDS epidemic in gay men as is the HIV virus itself. These acts of discrimination, which reduce our social capital, are disease-causal. President Obama’s support of marriage equality is disease-protective.

MARRIAGE EQUALITY AND PUBLIC HEALTH RESEARCH AND THEORY

The social drivers of disease are supported in theory and research. Because of the social conditions we experience, being gay is a fundamental cause⁷ of HIV and the other health conditions we experience as gay men. Ecosocial models, including the theory of syndemics,⁸ delineate that psychosocial burdens created by inequalities and discrimination are antecedents to disease across our lifetimes. The Centers for Disease Control and Prevention⁹ recently recognized the importance of these social drivers in preventing disease, including HIV, as well as the need to attend to the influences of community and societal drivers, and called for a holistic approach to prevention in which interventions must be enacted on both the individual and structural level. Changes on the more macro level require changes in policy and in laws. For gay men, this entails protections and liberties including but not limited to the right to marry. President Obama's call to action for marriage equality is such a structural change. The beneficial and disease-protective effects of laws, rights, and protection on the health of LGB individuals have also been demonstrated empirically. In a study of sexually minority men examining the effects of marriage equality in the State of Massachusetts, the data revealed significant decreases in medical and mental health care visits and mental health care costs in the 12-month period after the enactment of the law.¹⁰

CONCLUSIONS

Despite President Obama's bravery and righteousness in calling for marriage equality, our country continues to struggle with this issue, although recent polls now show that the majority of Americans support marriage equality and that the issue of same-sex marriage has not negatively influenced the President’s chances for re-election. Still, the right for gay men to marry remains elusive in the majority of US states. Unfortunately, until such time when gay men, and all LGB individuals more broadly, are conferred their rights under the law, we as a population will also continue to be unduly burdened by physical and mental health conditions, including HIV. President Obama has charted a course for a future that enhances the well-being of gay men. We can only hope that within one generation the entire country will follow suit, and in time these social conditions that compromise our health will be a thing of the past.