Suicide is the second leading cause of death in young people between the ages of 15 and 24, and for lesbian, gay, bisexual, and questioning students the risk is much higher. In a new JAMA Pediatrics study Julia Raifman and colleagues, report that state-enacted laws that legalize same-sex marriage were linked to a significant reduction in the rate of suicide attempts by high school students.We spoke with Julia Raifman of Johns Hopkins Bloomberg School of Public Health about the work.The study was motivated by evidence that lesbian, gay, and bisexual adolescents experience a number of health disparities, and I wondered whether unequal rights might be associated with them. I chose to focus on adolescent suicide attempts as one of the most extreme health disparities. In our study, 29 percent of lesbian, gay, bisexual, and questioning students reported attempting suicide in the past year, relative to six percent of heterosexual adolescents.We found that state same-sex marriage policies were associated with a lower proportion of adolescents attempting suicide. We found that there was a seven percent reduction in suicide attempts. We calculated that this would be equivalent to more than 134,000 fewer adolescents attempting suicide each year based on the population of the United States.The study is based on the natural experiment created by variation in the years when US states implemented same-sex marriage policies. We compared suicide attempts before and after same-sex marriage within 32 states that implemented same-sex marriage by January 1, 2015, relative to 15 states that did not.We controlled for each state, which allowed us to assess differences over time within each state rather than absolute differences in suicide attempts between states. Controlling for each state also controlled for all the differences between states that do not change over time, such as cultural differences. We also included control variables for state unemployment rates, which did change over time within states. What we could not control for were unmeasured state characteristics that might change over time, such as social support for LGB populations. The study design is the closest we can come to approximating a randomized trial in the real world, with a policy that would not be realistic to randomize.We did not investigate the mechanism by which state same-sex marriage policies reduced adolescent suicide attempts. A few possibilities are that state same-sex marriage policies reduced perceived stigma among LGB adolescents; that state same-sex marriage policies reduced stigmatizing behavior toward LGB adolescents by teachers, parents, or peers; or, as you mention, that campaigns for state same-sex marriage policies reduced perceived stigma among LGB adolescents. We did assess whether going on to implement same-sex marriage policies two years in the future was associated with adolescent suicide attempts, and found that this was not associated with suicide attempts; this finding suggests that same-sex marriage implementation or events happening closer to the time of same-sex marriage implementation were associated with the reductions in adolescent suicide attempts.The effects of same-sex marriage policies on suicide attempts would likely be more pronounced among teenagers, who have elevated rates of suicide attempts. Suicide is the second leading cause of death among adolescents between the ages of 15 and 24 years old. At the same time, teenagers are unlikely to marry in the immediate future. The reduction in suicide attempts with state same-sex marriage implementation suggests that the effect was not driven by marriage. It suggests that something else about state same-sex marriage policies, like having equal rights or improved social support for LGB populations accompanying state same-sex marriage policies, is likely responsible for the association between state same-sex marriage policies and adolescent suicide attempts.I think this is an area that requires further research. It is possible that state-level policies permitting equal rights could affect stigma in lower-level settings such as neighborhoods, schools, hospitals, homes, and individual teens, but this has not been studied. As you suggest, it is also possible that a more accepting environment is associated with implementing state same-sex marriage policies, and this also hasn’t been studied.Our study shows that state same-sex marriage policies reduced adolescent suicide attempts, which I think everyone would agree is a good thing. I hope that policymakers and the public will consider the potential health impacts of policies affecting LGBT rights.We hope this research will be able to inform policy and legal decisions affecting LGBT rights. For instance, there is a pending legal case on same-sex marriage in Houston, Texas, and we hope that this study may help provide information on potential consequences of a legal decision. There are also countries around the world considering enacting same-sex marriage policies, and we hope that this study may help inform these decisions.Image courtesy of Flickr user Eric