State Protection Alignment Index as a Measure of Structural Stigma’s Impact on the Mental Health of Sexual and Gender Minorities

Sexual and gender minority (SGM) populations are vulnerable to health disparities, including worse mental health when compared with cisgender, heterosexual populations. This is in part due to the stigma and discrimination they experience. In this study, we used a novel approach to examine structural-level stigma by determining which categories of statewide law and policy pro- tections for SGM people were associated with mental health outcomes among SGM adults. This was a cross-sectional study using law and policy data compiled by the Human Rights Campaign health data and collected through the Behavioral Risk Factor Surveillance System survey in the United States between January and December of 2019. We applied the weighted quantile sum regression to generate the Protection Alignment Index (PAI) from the 10 SGM categories of laws and policies and evaluated the influence of the PAI on the number of days of poor mental health and a diagnosis of depression. SGM people living in states with a higher SGM PAI, indicating greater protections, had significantly fewer poor mental health days. When the PAI increased one interquartile range (IQR.0.75), the log of expected poor mental health days significantly decreased .0.04 days (95% CI = .0.08, .0.01; p-value = 0.012). Additionally, the odds of depression was 22% lower (OR = 0.78; 95% CI = 0.62, 0.98; p-value = .033) when the SGM PAI increased one IQR (.0.77). Findings from this study indicate that whether laws and poli- cies discriminate against or protect SGM people impacts the levels of structural stigma and ultimately mental health. Advocating for more protective laws and policies may be a way to help improve the mental health of SGM populations.