The Equality Act Is Needed to Advance Health Equity for Lesbian, Gay, Bisexual, and Transgender Populations

The US House of Representatives passed the Equality Act (HR 5) on May 17, 2019, which would prohibit discrimination based on sexual orientation and gender identity in employment, housing, public education, and public accommodations (e.g., health care facilities, nursing homes, youth service providers, transportation systems, and retail and hospitality industries). Only 15 states (i.e., California, Colorado, Connecticut, Hawaii, Illinois, Iowa, Maine, Massachusetts, Minnesota, Nevada, New Jersey, New York, Oregon, Vermont, and Washington)¹ ensure that lesbian, gay, bisexual, and transgender (LGBT) people have comprehensive legal protections from discrimination across these sectors, leaving many LGBT populations potentially exposed to discrimination in employment, housing, education, and public accommodations. Indeed, LGBT people, because of their sexual orientation or gender identity, can still be terminated from employment in 29 states, denied housing opportunities in 29 states, harassed in K–12 public schools in 35 states, and denied access to public accommodations in 30 states.¹

DISCRIMINATION NEGATIVELY AFFECTS HEALTH

A large body of research has documented that exposure to discrimination is harmful to LGBT health. First, structural discrimination (i.e., the prejudice enhanced by our sociopolitical and legal systems) can create barriers to health care for LGBT people. For instance, before the nationwide legalization of same-sex marriage in 2015, state-level bans against same-sex marriage were associated with disparities in private health insurance for same-sex couples.² Interpersonal discrimination in health care can also amplify LGBT health disparities. For example, provider-based discrimination (e.g., denial of treatment or visits with “chosen family” who may not share biological or legal relationships with LGBT patients) and subtle microaggressions (e.g., misgendering LGBT people or assuming heteronormative families and relationships) in health care settings may discourage LGBT patients from seeking medical care when they need it.

Discrimination in non–health care settings can also affect LGBT health by facilitating anxiety, feelings of insecurity, and detrimental coping mechanisms (e.g., heavy alcohol consumption and tobacco use). A large body of research has attributed LGBT health disparities to “minority stress,” which is defined as the additional stressors that LGBT people experience related to the discrimination and stigma associated with their sexual orientation or gender identity.³ Interpersonal discrimination in the everyday lives of LGBT people remains an underlying determinant of LGBT health—and exposure to discrimination may vary widely across place and time. For instance, LGBT people living in parts of the United States with relatively high levels of structural stigma report feeling less safe compared with LGBT people in places that are more accepting of LGBT people. Thus, LGBT individuals in more politically or socially conservative regions of the country may be less likely to seek out community-based assistance and social supports in public spaces, only furthering their distance from social networks, health information, and other resources and opportunities that could alleviate minority stress.

Furthermore, many LGBT people experience discrimination early in life—which can have lasting effects across the life course. Public health research consistently demonstrates that discrimination against and peer victimization of LGBT students in K–12 schools are associated with elevated levels of self-harm, suicidal ideations, depression, and anxiety disorders. Although LGBT youths are more likely to engage in suicide attempts (the second leading cause of death among adolescents), state-level protections, such as same-sex marriage, are associated with reductions in suicide attempts among LGBT adolescents in public high schools.⁴ Although same-sex marriage laws have improved one dimension of health and well-being (e.g., suicide attempts) for LGBT youths, the Equality Act could reinforce legal protections and strengthen additional buffers against discrimination and peer victimization for LGBT people in public schools. In fact, some research has found that LGBT youths in places with protective environments—such as states and cities that allow gay–straight alliances or prohibit harassment based on a student’s sexual orientation or gender identity—were less likely to have suicidal thoughts compared with LGBT youths in less protective environments.⁵

Given the harmful effects of discrimination on LGBT health, legal protections from discrimination across multiple sectors (e.g., employment, housing, education, and public accommodations) are critical for achieving LGBT health equity. Public health research has demonstrated that state-level laws allowing LGBT people to marry has improved health insurance coverage, access to care, and mental health outcomes for LGBT populations.⁶ Other population-based research has found that health disparities for sexual minorities—particularly for gay and bisexual men—are narrower in states with comprehensive legal protections compared with health disparities for sexual minorities living in states without comprehensive legal protections (the Appendix, available as a supplement to the online version of this article at http://www.ajph.org, provides additional LGBT health policy research).⁷

SOCIAL DETERMINANTS ARE ESSENTIAL

The US Senate should consider the health implications of the Equality Act when considering its passage. Not only are health disparities costly to the health care system, but health disparities limit the full potential of the population. Adopting the Equality Act could improve access to care and overall population health for at least 10 million LGBT Americans—which is approximately the population size of North Carolina (the ninth largest state in the United States). The legal protections in areas of employment, housing, education, and public accommodations would ensure that the social determinants of health—or the conditions where we live, work, learn, grow, play, and age—are safer places for LGBT Americans. Broader acceptance and welcoming environments in health care, education, employment, housing markets, and other public accommodations will provide new opportunities for LGBT people to achieve optimal health in ways that the health care system cannot handle alone.

The Equality Act will also mitigate the discrimination that LGBT individuals may be subjected to in states where discrimination and stigma may be more rampant, such as the Midwest and Southern United States. Without action at the federal level, many of these states may never adopt nondiscrimination protections for LGBT residents, leaving them vulnerable to discrimination. Admittedly, the Equality Act may not have an equal effect on all LGBT people because individuals living at the intersections of multiple marginalized identities continue to experience multiple forms of discrimination: racism, sexism, classism, ableism, homophobia, transphobia, or xenophobia. The Equality Act, however, may serve as a stepping stone toward additional protections for LGBT individuals, including stronger laws protecting all LGBT people from hate crimes and conversion therapy, both of which still have not been made illegal by the vast majority of state legislatures.¹

Public health research suggests that legal protections from discrimination are associated with better LGBT health. Thus, the Equality Act is needed to ensure that all Americans can live with dignity and respect in all aspects of their lives, regardless of their sexual orientation or gender identity.