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Mark Hatzenbuehler, Ph.D.

RWJF Health & Society Scholar 2010-2012

Unraveling the Impact of Social Environments on the Health of Lesbians, Gays, and Bisexuals

The problem. Lesbian, gay, and bisexual individuals have more health and mental health problems than people who are heterosexual. Lesbian, gay, and bisexual youth attempt suicide at higher rates than heterosexual youth. Social policies that target sexual minorities also impact the health of lesbians, gays, and bisexuals. For example, mood, anxiety, and substance abuse problems significantly increased in lesbian, gay, and bisexual individuals who lived in states that passed constitutional amendments in 2004 banning same-sex marriage, compared to those in states without these amendments.

Scholar perspective. While in graduate school at Yale University, clinical psychologist Mark L. Hatzenbuehler, PhD, had noticed that many of the patients he treated had problems related to the social environment. He wanted to better understand how social factors contributed to adverse mental health outcomes for lesbians, gays, and bisexuals.

Hatzenbuehler knew that he could combine clinical psychology and epidemiology to do this. "Clinical psychology and epidemiology provide two different ways to focus on the problem: at the individual and social levels. Both are important for understanding health inequalities," he said.

After earning his MS, MPhil and PhD degrees in clinical psychology from Yale, Hatzenbuehler realized that he needed additional training in epidemiology and population health to move forward with his research goals. Hatzenbuehler got this training through the Robert Wood Johnson Foundation Health & Society Scholars program. In 2010, he began his two-year interdisciplinary fellowship at Columbia University, one of the six universities participating in the Health & Society Scholars program. For more information on the program, read the Program Results.

As a Health & Society Scholar, Hatzenbuehler conducted two key studies: one on the effect of social environments on suicide attempts by lesbian, gay, and bisexual teens and one on the effect of same-sex marriage laws on health care use and costs for gay and bisexual men.

Effect of social environments on suicide attempts by lesbian, gay, and bisexual teens. For the first study, Hatzenbuehler used data from the Oregon Healthy Teens Survey, an anonymous annual survey that asks middle and high school students to identify their sexual orientation; indicate how many times they have attempted suicide in the past 12 months; and identify suicide attempt risk factors such as level of depression, binge drinking, peer victimization, and physical abuse by an adult.

With data on 31,852 high school juniors from 34 counties (30,439 self-identified as heterosexual, 301 as gay or lesbian, and 1,112 as bisexual), Hatzenbuehler analyzed the social environment through a composite index that included the following:

  • Proportion of same-sex couples
  • Proportion of registered Democrats
  • Presence of gay-straight alliances in schools
  • School policies that protected lesbian, gay, and bisexual students (non-discrimination and anti-bullying policies).

Hatzenbuehler's findings. Lesbian, gay, and bisexual teens in Oregon were five times more likely to attempt suicide in the past 12 months than their heterosexual peers. However, lesbian, gay and bisexual youth living in a supportive community were 20 percent less likely to attempt suicide in the past year compared to those living in unsupportive communities. Hatzenbuehler reported these findings in Pediatrics (Vol. 127(5), 2011). Supportive communities include those with a high proportion of gay and lesbian couples, and schools with gay-straight alliances and anti-discrimination policies.

"The study provided a roadmap for how we can begin to reduce suicide attempts among lesbian, gay, and bisexual youth," said Hatzenbuehler. "One of the most important environments for youth is schools. There are three straightforward things schools can do to improve school climate: allowing gay-straight alliances, implementing anti-bullying policies, and also implementing anti-discrimination policies that are inclusive of sexual discrimination."

The study's results were widely covered by the media, including CBS News, Reuters Health, US News & World Report, and the Washington Post. The National Institutes of Health supported the study through a grant to the Center for Population Research in LGBT (Lesbian, Gay, Bisexual, Transgender) Health at the Fenway Institute in Boston, where Hatzenbuehler is a participating scientist. The center develops and supports research and education to improve the health of sexual and gender minorities.

Because of his suicide research, Hatzenbuehler received an invitation from the Centers for Disease Control and Prevention in 2011 to serve on an expert panel that explored the relationship between bullying and suicide-related behaviors. He wrote an article for the panel about anti-bullying policies to reduce suicide attempts in lesbian, gay, and bisexual youth. This article is scheduled for publication in 2013 in a special issue of the Journal of Adolescent Health.

Using a different dataset under a competitive research grant from the Health & Society Scholars program, Hatzenbuehler conducted a similar study of the social factors related to poor health outcomes in lesbian, gay, and bisexual youth. An article on this study was under review as of March 2013.

Effect of same-sex marriage laws on health care use and costs. For his study on the impact of same-sex marriage laws on health care use and costs of gay and bisexual men, Hatzenbuehler and colleagues surveyed 1,211 gay or bisexual male patients in a community-based health center in Massachusetts and reviewed outpatient billing records for medical and mental health visits in the 12 months before and after same-sex marriage was legalized in Massachusetts (in 2003).

Hatzenbuehler found a significant decrease in medical visits (13%) and costs (10%), and a decrease in mental health visits (13%) and costs (14%), compared with the 12 months before the law changed. Hatzenbuehler and his colleagues reported these findings in the American Journal of Public Health (Vol. 102(2), 2012).

"We've known for many years that marriage is good for health and longevity, particularly for heterosexual men," said Hatzenbuehler. "This study showed that marriage may also be beneficial for gay and bisexual men as well, in particular, in reducing health care use and costs."

The American Psychological Association cited Hatzenbuehler's research in its 2011 Resolution on Marriage Equality for Same-Sex Couples, which supports full marriage equality for same-sex couples. His research also has been submitted as evidence in a U.S. Supreme Court case to review California's Proposition 8 ban on same-sex marriage, scheduled to be heard in March 2013. The media, including CBS News, New York Daily News, US News & World Report, and USA Today, covered the study.

Addressing health disparities through a broader, interdisciplinary focus. After completing his Health & Society Scholars fellowship, Hatzenbuehler joined the Columbia faculty as an assistant professor of sociomedical sciences, a field that focuses on the social determinants of disease and health and emphasizes interdisciplinary work.

"I'm now in a school of public health rather than a psychology department," said Hatzenbuehler, who noted that this was not something he would have necessarily considered before participating in the Health & Society Scholars program. "I appreciated interdisciplinary approaches before the program. But after being surrounded by people from different disciplines for two years, I saw the intellectual excitement of that. It's a more effective way of addressing health disparities."

In 2012, Hatzenbuehler received a five-year Mentored Research Scientist Development Award from the National Institutes of Health to expand his work on the effect of social environments on the health of lesbian, gay, and bisexual youth.

For the 2012–2013 academic year, Hatzenbuehler is also the co-director of the Inequalities Center at Columbia, a multidisciplinary collaboration focused on understanding and addressing connections between social inequalities and health, which Hatzenbuehler compares to the Health & Society Scholars program. He is available to mentor Health & Society scholars who share his interests.

RWJF perspective. RWJF created the Health & Society Scholars in 2001 to build the field of population health. "There is a growing recognition that health is the result of the interaction of multiple factors including socioeconomic and physical environmental factors and health behaviors," said Pamela G. Russo, MD, MPH, senior program officer. "The evidence shows that these types of factors play a much larger role in determining health at the population level than do the traditionally considered health care and biological determinants of health. The program seeks to integrate paradigms and knowledge from a variety of disciplines to develop an understanding of how these determinants affect the health of populations, and thereby to design interventions with greater power to reduce health disparities," said Russo.