State policies permitting the denial of services to same-sex couple and sexual minority mental distress

Monday, June 24, 2019: 1:15 PM
Jefferson - Mezzanine Level (Marriott Wardman Park Hotel)

Presenter: Julia Raifman

Co-Authors: Ellen Moscoe; S. Bryn Austin; Mark Hatzenbuehler; Sandro Galea

Discussant: Elham Mahmoudi


Lesbian, gay, bisexual (LGB) people in the United States have a disproportionate burden of poor mental health. Between 2015 and 2018, 13 states passed policies permitting the denial of services to LGB and transgender people. We investigated whether state LGB denial laws passed in 2015 were associated with changes in sexual minority mental health between 2014 and 2016.


We used 2014-2016 Behavioral Risk Factor Surveillance System (BRFSS) data representative of adults aged 18-65 years in each state. We used data from three states that implemented LGB denial laws in 2015 and that collected data on sexual orientation in the BRFSS: North Carolina, Utah, and Michigan. We compared these states to six neighboring comparison states that collected data on sexual orientation: Virginia and Delaware, Idaho and Nevada, and Indiana and Ohio, respectively. The main outcome of interest was severe mental distress, defined as poor mental health in 14 or more of the past 30 days. We conducted a difference-in-difference-in-differences analysis, comparing changes in severe mental distress among LGB people before and after state LGB-denial policies in policy-change states to changes in mental distress among heterosexual people in the same states and among LGB people in comparison states. We estimated a linear regression model based on evidence that logistic regression estimates can be biased in the presence of fixed effects. The main exposure of interest was living in a state that implemented an LGB denial law in the prior calendar year and identifying as LGB, modeled as an interaction term. In addition to including binary terms for sexual minority identity and for states implementing LGB denial laws in the prior year, we adjusted for individual-level state, year, sex, race, ethnicity, age group, educational attainment, income, employment, and marital status. Controlling for each state using fixed effects had the effect of controlling for all time-invariant state characteristics. We conducted permutation tests to estimate statistical significance due to the small number of states in the analysis. We conducted several sensitivity analyses, including estimating a logistic regression model.


Prior to LGB denial policies, 13% of adults and 21% of LGB adults reported severe mental distress. In states that passed LGB denial policies in 2015, severe mental distress among sexual minorities increased 11 percentage points, from 22% in 2014 to 33% in 2016. There were one percentage point increases in mental distress among heterosexual adults in policy-change states and among LGB adults in comparison states. In the main analysis, LGB denial laws were associated with a 10 percentage point (95% confidence interval: 2 to 19 percentage points, permutation-adjusted p-value: 0.046) increase, equivalent to a 46% relative increase, in the proportion of sexual minority adults experiencing severe mental distress. Sensitivity analyses were consistent with the main results.


State LGB denial policies were associated with a 46% increase in the proportion of LGB adults experiencing severe mental distress. Lawmakers and courts considering LGB denial policies may wish to consider the relationship between these policies and increases in severe mental distress.