Corey Prachniak is an LGBT rights, HIV policy, and healthcare attorney. He serves on the Steering Committee of the Network for LGBT Health Equity and tweets @LGBTadvocacy.
Part I of this series can be found here.
As marriage and workplace equality pick up steam, some LGBT people and their allies think the fight is almost over. The data tells another story. At most, the marriage movement delivers trickle-down equality in terms of queer health, with folks benefitting less and less as one moves towards the fringes. If it is justice that we seek, this cannot be enough.
Marriage and workplace equality can relate to health disparities in one of three ways: (1) direct impact, (2) indirect impact, and (3) no impact at all.
1) Are there any health disparities that will be directly diminished by marriage and workplace equality? The short answer is “no.” Instead, these advancements in the law will only directly impact the disparity in rates of health insurance. To be sure, many LGBT health disparities are exacerbated by the fact that LGBT people on the whole are less likely to be insured. Marriage equality will extend opportunities for some same-sex spouses to get covered and workplace nondiscrimination laws will prevent people from getting fired and losing employer-sponsored insurance. But these are all indirect effects on actual health disparities.
Furthermore, increased access to insurance doesn’t change the behavior of insurers or medical providers in a way that would make them more responsive to LGBT needs. Rather, increased rates of insurance only opens up the existing, status quo healthcare market to more LGBT people. While this should not be overlooked as an accomplishment, it must be recognized as access to a broken system and not systemic change. And those who are already insured will not benefit at all from this development.
2) What health disparities are indirectly affected by these advancements? The changing legal landscape for queer people can have an indirect effect on health disparities in one of two ways: by changing the behavior of medical providers, and by changing the behavior of LGBT people themselves.
What medical practices might change? Over time, the mainstreaming of certain LGBT people will likely make medical professionals more comfortable with LGBT patients. This should mean a decrease from the 8% of LGBT people who a few years ago stated that they had been directly denied care for being LGBT, as well as the countless others who received some kind of disparate treatment.
However, marriage equality won’t necessarily make providers more comfortable with queer people disinterested in adapting a mainstream gender identity, orientation, or relationship structure. Providers today might treat with less hostility a gay man who has a partner and a child, but might not be more inclined to show respect for a genderqueer person in a polyamorous relationship. With about a quarter of transgender and gender-nonconforming persons reporting direct discrimination in healthcare, the folks with the greatest health disparities stand to benefit the least from the marriage movement.
Furthermore, greater acceptance of mainstream gay culture could backfire against queer sexual minorities: some providers might believe that now that gay people can get married, there is no reason for a patient to be promiscuous or not conform to a “normal” gender identity.
This backfire could also occur with well-meaning providers who already deliver substandard care to LGBT patients because they aren’t aware of queer health disparities. Normalizing same-sex marriage may lead well-intentioned providers to even further presume that the needs of the LGBT community are the same as those of everyone else. They’re not.
What LGBT behavior might change? It is even less clear that recent legal wins will lead to LGBT behavioral changes that will decrease health disparities. Sexual health disparities among LGBT people are tied in with ever-changing notions of what is “safer sex,” a term that acknowledges the fact that no sexual act is objectively either entirely safe or entirely unsafe.
The availability of same-sex marriage may make more LGBT couples aim for monogamous, long-term relationships. But that does not necessarily mean safer sex. In fact, people in long-term relationships are less inclined to use safe sex equipment (e.g., condoms or dental dams) because of the presumption that they are sexually active only with each other and therefore not exposed to disease. However, much of the spread of HIV – particularly in the heterosexual community – is within married couples, in which at least one partner is having extramarital sex and the other partner lacks the bargaining power or knowledge to request the use of safer sex practices.
In fact, the entrenched power dynamics and gender roles of the marriage framework have long had a negative effect on health. Historically, the system of marriage has been used to prevent women from being economically dependent, often forcing them to trade control over their bodies for financial support. Even today, there is disbelief among some that a man can be guilty of raping his wife since he is entitled to have sex with her. Congressional Republicans have made attempts to limit the definition of rape to that which was “forcible,” while a current congressional hopeful recently made headlines for claiming that a woman should never be able to file rape charges against her husband. (To be sure, marriage also offers certain legal protections, such as a right to shared resources, that could protect some same-sex partners from abuse.)
Additionally, changes in same-sex relationships may decrease disparities in alcohol, tobacco, and drug use because the mainstreaming of LGBT life has led to a decreased need to use bars, clubs, and parties as a way to gather and meet. But not everyone will choose to get set up by their pastor and never enter a club again, and even those who do will still face other factors that lead to substance abuse, such as LGBT-targeted ad campaigns by alcohol and tobacco companies and the mental health stress of being a sexual minority.
So it remains an open question as to whether allowing same-sex couples to marry will decrease or increase safer sex behavior, as well as whether it will decrease or increase intimate partner violence and substance abuse. It seems certain that it is not the best way to work towards improving these health disparities, and that transgender, gender-nonconforming, and nonmainstream queer people have the least to gain from any potential changes.
3) What health disparities will definitely not be improved by recent legal victories? There are some health disparities that result from inherent differences between the LGBT population and the rest of society. Because HIV is more easily transmitted to a receptive sexual partner, and because heterosexual cisgender men do not (as a group) have receptive anal sex, there will always be higher susceptibility among gay men, bisexual men, and transgender women. Similarly, this population will always have an increased risk of anal cancers.
Lesbian and bisexual women have been found to be at greater risk of breast and cervical cancer than the female population in general, and this is at least in part because of inherent differences in sexual practices. Same-sex marriage may lead to more lesbian and bisexual women giving birth, which could decrease the risk of some cancers. But we can presume that the birthrate among women having sex with women will always remain lower than heterosexual women, so there will always be disparities.
Society’s general movement towards qualified acceptance of the LGBT community will hopefully lessen the mental health disparities among LGBT people. However, as people become comfortable with the idea a same-sex couple getting married, that will not necessarily help a young a person who identifies as transgender, or who identifies as neither male nor female. It will not help a child whose parents tell her that she can date another woman if she wants, but not a transgender boy she met at school. It will not help a person whose boss would be fine knowing that he has a husband, but not knowing that he lives with a male and a female lover with whom he collectively raises a child.
Besides, some mental health disparities are partially the result of physical health disparities. For example, the stigma that comes with being HIV-positive can cause great stress, so as long as the LGBT community remains more at risk for HIV infection, and as long as there is stigma attached to it, LGBT people will be more susceptible to this particular mental health strain.
And because same-sex marriage only has a marginal legal effect on the transgender community, and transgender people are most likely to be left out of nondiscrimination laws, their health disparities will be least relieved by recent legal developments. Greater access to healthcare insurance still would not help transgender people whose plans have broad exclusions of “transgender-related care.”
So, what do we do? It stands to reason that if we care about justice, we should focus our energy on those who face the greatest injustice. The marriage movement has not done that – at least not with respect to health, which is the most basic aspect of our dignity as humans. Instead, those with the greatest disparities – queer people whose gender identities, orientations, and sexual practices remain outside the mainstream – have been helped least of all.
We cannot be content to wait for the benefits of the marriage movement to trickle down and help those at the “bottom” of the social ladder.
Part III will suggest a new path forward.