Marriage (Same Sex Couples)

Memorandum submitted by Dr Peter G. May (MB 102)

Marriage (Same Sex Couples) Bill and Public Health

Summary. The only medical submission to the Government’s consultation on Equal Marriage in 2012 came from the Royal College of Psychiatrists. This has not provided a balanced discussion of the Public Health issues at stake. Their contention that mental health problems in the LGB community can be improved by introducing Equal Marriage as a public health strategy is founded on irrelevant and ambiguous research. Furthermore, they ignore the causes of mental ill health problems that stem from lifestyle factors, which General Practitioners are in a much better position to observe.

The author, Dr Peter May MRCGP has 30 yrs of experience in urban General Practice in Southampton. He is now retired.

1. The main academic specialties In the Royal College of Psychiatrists are represented by Faculties and Sections. The College also has some Special Interest Groups (SIGs), for example on Spirituality and Philosophy, which provide opportunities for members to meet together, promote discussion and provide support. All members may apply to join them. They are self-selected groups and are not appointed by the College. The submission to the Home Office Consultation came from the "Lesbian, Gay and Bisexual Mental Health SIG" chaired by Prof. Michael King. It was submitted with the approval of the Central Policy Committee of the College.

2. While some SIGs are large and active, this group is not. The College boasts a membership of 15,000 specialists across the world, but a recent survey from the Group attracted just 58 responses, only eight of whom had attended a meeting of the group in the previous four years. Respondents to that survey chose a subject for a symposium, but the event was cancelled through lack of interest. In other words, not many psychiatrists take an interest in this Group. Their report to the Home Office consultation bears only the name of the chairman, Prof. Michael King.

3. The report states prejudicially that to define secular marriage only in heterosexual terms is a form of institutional discrimination on the basis of sexual orientation [1] . It then gives evidence that public policies can greatly increase perceived discrimination and asserts that the resultant ‘minority stress’ experienced by LGB people is an important contributor to their health problems.

4. Recently, the mental health problems among homosexuals, well documented in other countries, have been publicly recorded in the UK. [2] In a random sample from the population of 7,403 adults, rates of depression, anxiety, obsessive-compulsive disorder, phobia, self-harm, suicidal thoughts, and alcohol/drug dependence were all significantly higher in homosexual respondents.

5. Is this the result of homophobic discrimination? Perceived discrimination implies having a sense of being discriminated against. Also referred to as ‘minority stress’, it leads to generalised feelings of anxiety, oppression, hopelessness, isolation and sadness. Importantly, in the context of this discussion on public health, that UK study recorded that the level of reported ‘perceived’ discrimination in UK was comparatively low at 4.9%, being only 3.3% greater than that experienced by heterosexuals in the study.

6. Acknowledging the benefits of UK civil partnerships, the RCPsych submission claims that marriage equality, "will further reduce" the discrimination [3] and lead to greater social inclusion and improved health. The front cover summary sheet states the case more modestly, namely that "marriage equality could reduce the discrimination". That anyway is surely possible. But what evidence does the College put forward for their confidence that it will reduce discrimination?

7. They refer to the Australasian Drug and Alcohol Review [4] to show that gay and lesbian communities consume more drugs and alcohol than heterosexual groups. [5] [6] For instance, 61% of lesbian women, compared with 24% of heterosexual women, have had a substance disorder at some point in their lives. [7] They then quoted a comprehensive systematic review that shows that the relative risks of gays and lesbians developing substance use disorder was at least twice that of heterosexuals. [8]

8. The Review then asks the crucial question of why gay and lesbian people should be more disposed to develop problems with alcohol and other drugs? They concede a number of interrelated factors, mentioning three: meeting places, the difficulties of ‘coming out’ and discrimination. The Review concludes that "one of the clearest strategies" is to legalise gay marriage because married people in general have better mental health.

9. They justify this by saying that health benefits of marriage are not limited to financial advantages. They include access to Government support (which would not actually apply in the UK where it is equally available to Civil Partnerships) and greater social support. No attempt is made to justify the idea that merely calling civil unions "marriages" will lead to improved mental health. In same-sex marriage and heterosexual marriage, we are comparing two very different, self-selected groups. Will both sorts of marriage prove equally health affirming?

10. To support this public health policy, the Review cites the findings Hartzenbuehler et al [9] . This study is also cited in the RCP submission to the Government and therefore needs to be examined carefully. This research was carried out in America, again in a very different context to the UK. In 1996, the US Congress passed the Defence of Marriage Act, defining marriage as a legal union solely between a man and a woman. During the 2004 election, a trend got underway whereby a series of 14 states approved "banning amendments", preventing civil unions or same-sex marriages from being legalised in that state. According to the researchers, this happened in the context of public campaigns fostering a negative climate for the same-sex community. LGB people were confronted with increasing "exposure to stressors, including misleading portrayals and negative stereotypes in the media and hostile interactions with neighbours, colleagues and family members." Unlike the situation in the UK, where discrimination is known to be low, in America overt discrimination was greatly aggravated by these banning amendments, particularly in states which did not have anti-discrimination laws in place.

11. To address the impact of institutional discrimination on mental health, the authors set out to see if there were higher rates of psychiatric disorders among LGB individuals living in states with constitutional amendments banning gay marriage than among LGB individuals living in states without such amendments.

12. The RCPsych presented these findings from America as evidence to the UK Government, that in a nation with Civil Partnerships, where there is strict legislation to control discrimination, and where there are currently documented low discrimination rates, [10] that they would nonetheless be evidential grounds to support the introduction of marriage equality.

13. The researchers themselves drew rather tentative conclusions from their study. For instance, in states with banning amendments they did find significantly increased levels of general anxiety and alcohol disorders among the LGB populations. But contrary to expectations, they found statistically significant levels of drug use disorders among those living in states without amendments. They also found statistically significant increases in the prevalence of panic, generalised anxiety and alcohol use disorders among the heterosexual respondents, though the increase was smaller than in LGB populations.

14. They also had other reservations. Only 6 states in the study had some form of protection for same-sex couples. This did not give enough statistical power to test the hypothesis that pro-gay marriage policies would improve the mental health of LGB people in those states. It was possible that in states without non-discriminatory legislation, healthier and wealthier LGB people had moved to states with more liberal policies.

15. They also recognised that sexual identity labels can show fluidity, which could have led to misclassification of some LGB participants over the study period. Neither could they examine whether these symptoms would be short-lived or persistent, once the negative political and media campaigns had subsided. Although this was a relatively large study, the number of respondents meeting diagnostic criteria for psychiatric disorders in states with amendments was relatively small.

16. Therefore, they concluded "the results must be interpreted with caution and they require replication with larger samples of LGB respondents". Yet it was held by the RCPsych submission that these findings "are consistent with an argument that implementing social policy changes to abolish institutional forms of discrimination may ultimately reduce mental health disparities in LGB populations, an important public health priority." [11] Unfortunately, here we have just one study, which shows some conflicting results and calls for more research before drawing firm conclusions.

17. The RCPsych submission cited a further American study. [12] Argued from the American situation, where marriage benefits under federal or state law would result in improved access to health care, this has no obvious relevance in UK under the NHS.

18. The RCPsych submission then asks the pertinent question, Do LGB people want marriage equality? They say that "LGB people around the world are interested in having the freedom to marry", and they quote an Australian survey of same-sex attracted people, which found that 78% of respondents reported that they would like to see marriage become available as an option for same-sex couples.

19. Yet at least 85% of gays in the UK have declined the option of entering Civil Partnerships, so it is difficult to expect a sudden surge of interest. They may want the "freedom to marry" available as "an option", but most do not evidently want it for themselves.

20. The RCPsych submission dogmatically asserts that opponents of marriage equality produce no evidence to support the claim that the institution of marriage will be harmed by fundamentally redefining it. Rather, they assert that even to claim that equal marriage will harm the upbringing of children contributes to the ‘minority stress’, which LGB people experience. [13] That may be the case, but it should not stop health professionals from addressing that vital question!

21. It is widely recognised that the ‘gold standard’ in the upbringing of children is for them to be brought up by their biological mother and father. No-one else will love and care for them as much as they do. Boys and girls need the complementarity of the sexes in their parenting. Boys need their father and their mother, and so do girls.

22. Now this is a very important matter. The RCPsych claim in their submission that there are no health arguments in favour of denying marriage equality. [14] This is patently not the case. The largest and best study on this subject was published 2012 by the University of Texas. [15] Greeted with howls of protest from the Gay Community, the University was forced to withdraw the paper while it performed a thorough analysis of its design, structure, results and conclusions. It eventually gave the study a completely clean bill of health. Any dismissal of its findings now, which is not grounded in a proper discussion of the inevitable limitations of the study and a sound interpretation of its data, must face the charge of bias.

23. Mark Regnerus surveyed both a large and, importantly, a random sample of American young adults, who were raised in one of eight different types of family arrangement. With nearly 3000 respondents, this was a much larger study than nearly all its peers. Measuring 40 different outcome variables, he compared them according to their family structure. The study clearly reveals that children appear most apt to succeed well as adults if they spend their entire childhood with their married mother and father. The children of women brought up by a mother in a lesbian relationship had the most suboptimal outcomes (measured in categories such as education, depression, employment status, drug use).

24. Certainly marriages fail and parents die but such things are not planned for. Step-parents usually provide for the best default arrangement. It is quite another thing to set out intentionally to create what we now have good evidence to see as a sub-optimal family arrangement. This puts the desires of the couple ahead of the needs of their children and the well-being of the wider society.

25. Children need the permanent and exclusive commitment of their parents and are unstettled and harmed when that fails. The LBG community, however, has a very poor track record in providing exclusive, stable relationships. As Michael Shernoff wrote: "One of the biggest differences between male couples and mixed-sex couples is that many, but by no means all, within the gay community have an easier acceptance of sexual nonexclusivity than does heterosexual society in general. " [16]

26. Numerous studies have documented this. McWhirter and Mattison found that all couples whose relationship had lasted more than five years had incorporated some external sexual activity into their relationship. [17] Exclusive monogamous relationships among gays seem destined to be the experience of only a small minority.

27. Changing the definition of marriage will not bring stability to the world of marriage. As Stanley Kurtz of the Hudson Institute, the American futurology think-tank, has said, "what gay marriage is to homosexuality, group marriage is to bisexuality." Bisexuality is more common among women. The aggregate pooling of all recent studies in April 2011 shows that bisexuality is now the largest sexual minority identity label. [18]

28. The next logical step therefore from the promotion and full acceptance of homosexuality is the promotion of bisexuality. Kurtz again: "It is easy to imagine that, in a world where gay marriage was common and fully accepted, a serious campaign to legalize polyamorous unions would succeed. We’ll someday be endlessly told that not all marriages are monogamous." [19]

29. As of July 2009, it was estimated that there were more than 500,000 polyamorous relationships in the United States. In Holland and Brazil now three-way polyamorous unions are legal.

30. What other causes of mental health problems besides discrimination might the RCP Psychiatrists have mentioned? It is well recognised that there is a higher incidence of general health problems in the gay community, and physical illness itself, as well as bereavement, causes anxiety and depression.

31. Gays and Lesbians are much more likely to suffer from sexually transmitted infections (STIs) than heterosexuals. This is true for all types of STIs. More than a third of all new cases of gonorrhoea are in men who have sex with men. [20] It is estimated that their risks of contracting syphilis, gonorrhoea and HIV/AIDS are some 50 times greater than for heterosexuals. (Although in UK a similar number of heterosexuals suffer from HIV/AIDS, LGB people amount to only 1.5% of the population. [21] )

32. Various reasons have been put forward to account for this vastly increased risk but the most significant probably concerns the thin rectal lining compared to the thick musculo-fibrous lining of the vagina, and this risk is present in both giving and receiving anal sex.

33. Despite all efforts, HIV incidence of new cases has remained steady for 10 years. Latest research [22] shows the HIV rate among men who have sex with men (MSM) in UK is at an all-time high. Analysing data from 1990-2010, it is estimated that without retroviral treatment, which reduces infectivity, the incidence would have increased by a further 68%. Overall, 1 in 20 MSM are infected with HIV, which without treatment takes about 10 years to develop into AIDS.

34. Although 680 people with HIV in UK died in 2011, life expectancy has improved with treatment. In 1996, a 20 year old with HIV could expect to live to 50 yrs. In 2008, that had increased to 66 years. However, the average life expectancy of a 20 year old male is 85 yrs, so even with anti-retroviral treatment, HIV reduces life expectation by around 20 years. This is partly because half of those infected were diagnosed late. It is estimated that one in four people with HIV in UK currently remain undiagnosed, presenting a serious risk of spreading the infection to other partners.

35. The health risks involved in teaching children and adolescents that same sex relationships are equally valid and as desirable as heterosexual relationships, and thereby encouraging teenage experimentation, are unconscionable.

36. The estimated annual cost of treatment and care for HIV is £858 million. [23] The savings to be made by preventing new cases, who would now require lifetime treatment, are estimated at £320k per person. [24]

37. Several of these infections progress to cause cancers. Cervical, anal, mouth, prostate, liver, lymphoma and skin cancers have all been directly linked to STIs.

38. In general, lesbian, gay and bisexual people have more than twice the rate of suicide attempts of heterosexuals. [25] While women are particularly at risk of alcohol and drug dependence, the men are at higher risk of suicide attempts.

39. Will gay marriage ease the suicide rate? Denmark should provide its LGBT community with one of the lowest levels of discrimination in the world. Same-sex activity was legalized there in 1933, and since 1977, the age of consent has been 15 yrs, irrespective of orientation or gender. It was the first country to legalise same-sex unions in 1989. This provided the basis for a unique study. Over a twelve-year period, it found that death in Denmark from suicide among men in same-sex registered partnerships was eight times greater than among men in heterosexual marriages. [26]

40. Another major cause of low mood is broken relationships. It is recognised that many homosexuals have difficulty forming and maintaining intimate and exclusive relationships. Few things destroy relationships more acrimoniously than jealousy. Then there is the lack of children and wider family ties, which lead to isolation and loneliness, rather than support.

41. If one is trying to understand the causes of low mood in the lesbian and gay communities, not least in the UK, there are far more powerful forces at work than perceived discrimination and stigma. All these things, in addition to discrimination and stigma, contribute to the poor mental health and high suicide rates found in the same-sex community.

42. Medical science progresses by peer review. Before publication, papers are sent to scholars in the field for approval. In particular, a Journal Editor wants to know if the authors have been biased and selective in their treatment of evidence? No such process appears to have been at work in the RCPsych submission.

March 2013

[1] RCPsych. College responds to Equal Civil Marriage consultation. June 2012.p.5

[2] Chakraborty A, King M et al. Mental health of the non-heterosexual population of England .

[2] Br J Psychiatry 2011;198:143-8

[3] RCPsych. C ollege responds to Equal Civil Marriage consultation. June 2012 p.5

[4] Ritter A et al, Why the alcohol and other drug community should support gay marriage .

[4] APSAD Drug and Alcohol Review Vol 31, pp1-3, January 2012.

[5] Corliss HL et al. Sexual orientation and drug use in a longitudinal cohort study of U.S. adolescents.

[5] Addict Behav 2010; 35:517-21

[6] Bolton SL, Sareen J. Sexual orientation and its relation to mental disorders and suicide attempts:

[6] findings from a nationally representative sample. Can J Psychiatry 2011; 56:35-43

[7] ibid

[8] King M, Semlyen et al. A systematic review of mental disorder, suicide and deliberate self harm in

[8] lesbian, gay and bisexual people. BMC Psychiatry 2008;8:1471-224

[9] Hartzenbeuhler ML et al. The impact of institutional discrimination on psychiatric disorders in

[9] lesbian, gay and bisexual populations:a prospective study Am J Public Health 2010March;100:452-9

[10] Chakraborty A, King M et al. Mental health of the non-heterosexual population of England .

[10] Br J Psychiatry 2011;198:143-8

[11] RCPsych. C ollege responds to Equal Civil Marriage consultation. June 2012 p6

[12] Buffie WC, Public Implications of same-Sex Marriage. American Journal of Public health: June

[12] 2011, Vol 101, No 6, pp986-990

[13] RCPsych. College responds to Equal Civil Marriage consultation. June 2012. p5.

[14] Ibid p.2

[15] Regnerus M. How different are the adult children of parents who have same-sex relationships?

[15] New Family Structures Study, University of Texas.2012

[16] Shernoff M. Family Process Journal, Vol.45 No.4, 2006

[17] McWhirter & Mattison, The Male Couple How Relationships Develop, 1984. pp252-3

[18] Gates Gary J. How many people are lesbian, gay, bisexual? Williams Institute, April 2011

[19] Kurtz S. Here come the Brides The Weekly Standard, 26.12.2005

[20] Health Protection Agency, 2012

[21] Office of National Statistics, 2012

[22] Health Protection Agency Report: HIV in the United Kingdom 2012

[23] Department of Health. Programme Budget 2009- 2010. Dept of Health 2010 [cited 2012 Nov 2]


[24] Health Protection Agency 2009

[25] King M, Semlyen et al. A systematic review of mental disorder, suicide and deliberate self harm in

[25] lesbian, gay and bisexual people. BMC Psychiatry 2008;8:1471-224

[26] Mathy RM et al. The association between relationship markers for sexual orientation and suicide:

[26] Denmark1990-2001 Soc. Psychiatry Psychiatr Epidemiol (2011) 46:111-117

Prepared 8th March 2013