LAUSR

Legalization of Same-Sex Marriage and Drop in Adolescent Suicide Rates: Association but Not Causation To the Editor Raifman et al1 use robust statistical tools to demonstrate an association between the legalization of same-sex marriage (SSM) in the United States and a decrease in adolescent suicide rates, the absolute reduction being 0.6 percentage points for all students and 4 percentage points in sexual minorities. Nevertheless, we are concerned about the representativeness of their sample. Indeed, 30.2% of all students included in their sample belong to the “sexual minorities” group (Table 21). Consequently, the proportion of suicide attempts from this group (34.1% in 2015) and the net benefit potentially attributable to the legalization of SSM might be artificially inflated. Moreover, by concluding that “implementation of same-sex marriage policies reduced adolescent suicide attempts,”1 they jump over a few steps in the journey from association to causation. First, they did not report the motives of the suicide attempts, making it impossible to know whether these were attributable to the perspective of not having access to marriage or to the lack of social attention. Second, the contribution of other general policies aimed at promoting equality and preventing suicide is not clearly individualized. Such policies are likely to produce a more significant effect in sexual minorities because they bear the greatest risk.2 The association reported might just reflect a global improvement over time in states’ commitment to create supportive environments for minorities. Indeed, when placed in supportive school environments, sexual minority students experience lower rates of depression and suicidal ideation and have fewer plans and attempts of suicide than recorded in less supportive conditions.3 Finally, in future studies, the authors might want to analyze the differences in adult suicide rates across states depending on whether the state adopted SSM policies and also within the same state before and after the implementation of these policies. Higher suicide rates in sexual minority adults would mean that the problem has just been transferred to a later stage of life. Focusing on SSM is setting marriage as the ultimate goal of sexual minorities and considering it as a magic potion when the individuals might not necessarily have the same view. We should focus on the reduction of stigma that is known to have a more immediate effect on adolescent mental health, independent of the benefits of marriage,4 rather than nurturing a far-off dream of SSM that might not give a satisfactory answer to their existential questions.