The case for taking an organisational position on marriage equality

On Friday 1st September 2017, twenty-three Victorian metropolitan and regional community health organisations  issued a joint statement and media release in support of marriage equality. 

Among the supporting resources is this brief evidence review, written on behalf of cohealth, outlining the public health case for why health and other non-government organisations should take an active position in relation to the issue.


“Professional bodies and other peak organisations have a moral duty to reflect on the available data which clearly demonstrates the positive health impacts of marriage equality and take a position on this issue.” (1)

“It’s imperative that during this time [health] services provide an LGBTI inclusive and friendly space. It’s also important for services to profile publicly that they are LGBTI inclusive and friendly. This will let prospective LGBTI clients know they’re welcome; that they will receive the same high quality service as everyone else.” (2)

The Australian marriage equality campaign entered a new phase in August 2017 with the announcement of the voluntary Australian marriage law postal survey (3). The survey is expected to start on September 14 2017.

Despite widespread support for reform across all sections of the community regardless of age, location, education and religious and political affiliation (4), as well as from many corporate entities, local councils, NGOs, churches and clergy (5), concern about the potential for a socially divisive campaign remains high.

In this heightened environment, some organisations may be tempted to view the debate as one of individual or personal preference, and to refrain from taking an organisational position.

The evidence supports taking a strong public health response in favour of marriage equality.

Higher rates of anxiety and depression, suicide, drug and alcohol use, and other forms of poor mental and physical health among LGBTI people, particularly younger people, are well documented (6).

These poorer health and wellbeing outcomes are frequently associated with ‘minority stress’ arising from experiences of individual and structural discrimination (7).

Sexual minorities living in high-prejudice communities experience substantially higher rates of suicide, violence and cardiovascular disease for example, and at a much young age (8). The introduction of laws limiting marriage to opposite-sex couples has been specifically associated with poorer health and wellbeing outcomes among LGBTI people (9).

Conversely, the introduction or existence of marriage equality laws has been found to have a positive impact on the health and wellbeing of LGBTI people (10). Improvements have included reducing the suicide rate of young people of high school age (11), and increasing access to (12), and utilisation of health services by both partnered and non-partnered LGBTI people (13).

Being in a legally recognised same-sex relationship, and a marriage in particular, has been found to eliminate many of the mental health differentials between heterosexual and LGB people (14). Recognised relationships deliver a range of protective factors, particularly for young people (15), and LGBTI people in legally recognised relationships report lower levels of stress, fewer depressive symptoms, and more meaning in their lives (16).

Harms to LGBTI mental and physical health have been found to be most acute during campaign periods. In the US for example LGBTI people living in states running marriage equality referenda experienced a 37% increase in mood disorders; 42% increase in alcohol-use disorders; and 248% in generalised anxiety disorders compared with those in states where referenda did not occur (17). This is in part because direct democracy approaches such as plebiscites and surveys have been found to lack the filtering mechanisms needed to protect minority groups from their harshest effects (18).

Concerns about the impact of a socially divisive campaign on children and family members have also been cited with the impact of referenda debates on family members including feelings of anger, distress and fear (19).

As well as impacting on the health, wellbeing and help-seeking behaviours of LGBTI people as service users, periods of highly public and contentious debate are also likely have impacts for employees in health, welfare and community sector settings.
These may include LGBTI and other staff experiencing stress/anxiety, the possible rise of anti-LGBTI or anti-religious/cultural sentiment, and the creation of an “us and them” culture. Each of these has the potential to impact on workplace performance and general staff wellbeing (20).

Combined, these elements pose a range of significant public health risks emanating from the absence of marriage equality in Australia that are likely to be exacerbated during the intensity of the marriage postal law survey campaign.

For these reasons many health, welfare and community sector peak organisations have concluded that they must take a proactive stand in relation to marriage equality. These include for example ACOSS, the Public Health Association of Australia (PHAA), Australian Medical Association (AMA), Australian Healthcare and Hospitals Association (AHHA), Relationships Australia, MIND Australia, Australian Psychological Society (APS), Australian Medical Students Association (AMSA), Australian Nursing and Midwifery Federation (ANMF), Royal Australian and New Zealand College of Psychiatrists (RANZCP), the Australian Services Union (ASU), Health and Community Services Union (HACSU), the Australian Local Government Association (ALGA), and many others (21).

Similarly, many secular and religious non-government organisations have actively stated their support for marriage equality and/or their LGBTI staff, including Australia’s largest Catholic not-for profit health and aged care provider, St Vincent’s Health Australia (22).

Any organisation whose interests include promoting evidence-based practice; mental and physical health and wellbeing; social inclusion; access and equity; and justice and human rights is similarly duty-bound to speak up in defence of equality, diversity and respect.

(1) Kolstee, J. and Hopwood, M. (2016). The impacts of marriage equality and marriage denial on the health of lesbian, gay and bisexual people: Evidence review and annotated bibliography. ACON and the Centre for Social Research in Health UNSW.
(2) ACON (2016). A guide for health services to support LGBTI clients during the marriage equality debate.
(3) Australian Bureau of Statistics (2017). Process for the Australian marriage law postal survey.
(4) Australian Marriage Equality (2016). Information sheet: Growing public support for marriage equality; Australian Marriage Equality (2017). Marriage equality summary statistics; and Perales, F., and Campbell, A. (2017). Revealed: Who supports marriage equality in Australia – and who doesn’t. The Conversation August 30, 2017.
(5) see for example Australian Marriage Equality (2016). Join corporations that support marriage equality.
(6) Leonard, W., Lyons, A., and Bariola, E. (2015). A closer look at private lives 2 – Report. Australian Research Centre in Sex, Health and Society, La Trobe University.
(7) Kolstee, J. and Hopwood, M. (2016). The impacts of marriage equality and marriage denial on the health of lesbian, gay and bisexual people: Evidence review and annotated bibliography. ACON and the Centre for Social Research in Health UNSW.
(8) Hatzenbuehler, ML., McLaughlin, K., Keyes, K., and Hasin, D. (2010). The impact of institutional discrimination on psychiatric disorders in lesbian, gay, and bisexual populations: a prospective study. Am J Public Health. 2010;100(3):452–459
(9) ibid.
(10) ibid.
(11) Raifman, J., Moscoe, E., Austin, S. (2017). Difference-in-differences analysis of the association between state same-sex marriage policies and adolescent suicide attempts. JAMA Pediatr. 2017;171(4):350–356. doi:10.1001/jamapediatrics.2016.4529.
(12) Gonzales, G. (2014). Same-sex marriage: A prescription for better health. The New England Journal of Medicine, 370;15 pp 1373-1376 DOI:10.1056/NEJMp1400254
(13) Hatzenbuehler, ML., et al. (2012). Effect of same-sex marriage laws on health care use and expenditures in sexual minority men: a quasi-natural experiment. Am J Public Health2012;102:285-91.
(14) Wight, R., LeBlanc, A., and Badgett, M. (2013). Same-sex legal marriage and psychological well-being: Findings from the California health interview survey. American Journal of Public Health 103, no. 2 (February 1, 2013): pp. 339-346.
(15) Bariola, E., Lyons, A. and Leonard, W. (2015). The mental health benefits of relationship formalisation among lesbians and gay men in same-sex relationships. Australian and New Zealand Journal of Public Health, 39: 530–535. doi:10.1111/1753-6405.12432.
(16) Riggle, E., Rostosky, S., and Horne, S. (2010). Psychological distress, well-being, and legal recognition in same-sex couple relationships. Journal of Family Psychology : JFP : Journal of the Division of Family Psychology of the American Psychological Association (Division 43). 24. 82-6. 10.1037/a0017942.
(17) Hatzenbuehler, ML., McLaughlin, K., Keyes, K., and Hasin, D. (2010). The impact of institutional discrimination on psychiatric disorders in lesbian, gay, and bisexual populations: a prospective study. Am J Public Health. 2010;100(3):452–459
(18) Lewis, D. (2011). Direct democracy and minority rights: Same-Sex marriage bans in the U.S. States. Social Science Quarterly, vol 92, no 2, 364-383, DOI: 10.1111/j.1540-6237.2011.00773.
(19) Arm, J., Horne, S., and Levitt, H. (2009). Negotiating connection to GLBT experience: Family members’ experience of anti-GLBT movements and policies. Journal of Counseling Psychology 2009, Vol. 56, No. 1, 82–96. American Psychological Association
(20) ACON (2016). Supporting your employees affected by the debate on marriage equality. Pride in Diversity.
(21) Australian Marriage Equality (2016). Join non-profit organisations that support marriage equality.
(22) Ho, T., Robertson, P., and Hall, T. (2017). A message from Toby Hall: Letter to members of SVHA’s health and aged care ministries. 21st August 2017.

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