Introduction

In the USA, lesbian, gay, bisexual, transgender, and otherwise queer-identifying (LGBTQ +) people have seen increased legal rights and protections over the past 30 years at the federal level through numerous legal and judicial determinations. These advancements include decriminalizing same-sex sex, marriage equality, and the determination of sexual orientation and gender identity as protected statuses for employment discrimination. Despite changes at the federal level, in recent years, several anti-LGBTQ + laws (laws that restrict the rights of LGBTQ + people) have been proposed and passed at the state level. These laws include religious exception policies that allow social and health services to LGBTQ + people to be denied based on religious grounds (Wang et al., 2016). Further, several states have proposed laws restricting transgender individuals’ ability to use restrooms and participate in athletic teams that align with their gender identities (Bagagli et al., 2021; The Associated Press, 2022). One law that gained substantial attention in 2022 was Florida’s HB 1557, the “Parental Rights in Education” bill, which has come to be known as the “Don’t Say Gay” law. This legislation prohibits the discussion of sexual orientation or gender identity in public school classrooms from kindergarten through third grade (Diaz, 2022). The law also grants parents the power to levy lawsuits against teachers or schools they believe contravene the law ("Parental Rights in Education," 2022). The threat of litigation suggests that school districts may cautiously guide educators to avoid saying or doing anything that could possibly be construed as discussing LGBTQ + people or identities. Indeed, lawyers have told teachers in Orange County, Florida, public schools that they should be careful not to wear rainbows; avoid mentioning same-sex spouses or displaying any pictures of them; and ensure they remove safe-space stickers from their classroom doors (Izaguirre & Gomez Licon, 2022).

Following Florida’s lead, twelve other states quickly proposed similar laws (Diaz, 2022), signaling the rapid spread of this type of legislation. These states include Southern states such as Alabama, Georgia, and South Carolina, as well as Midwest states such as Iowa, Indiana, and Ohio. Policies that silence discussion about LGBTQ + identities such as Florida’s “Don’t Say Gay” law contribute to the persistent marginalization and stigmatization of LGBTQ + people. Building off of existing research that shows how marginalization and stigmatization of LGBTQ + youth lead to worsened mental health and increased risk for depression, self-harm, and suicide (Hatchel et al., 2021; Madireddy & Madireddy, 2020; Rhodes et al., 2019), we assert that these policies threaten efforts to advance health equity for all sexual and gender minorities. In this article, we argue that anti-LGBTQ + laws such as Florida’s HB 1557 have multi-level health consequences that demand policy action and research attention. We indicate research priorities using theoretical and methodological approaches that highlight the complexity of these issues, prioritize community input, and work to reverse harmful policy adoption.

Individual Impacts: Social Stressors and Exacerbating Health Disparities

It is well-established that social marginalization and discrimination result in LGBTQ + populations experiencing elevated rates of depression, anxiety, stress, and suicidality compared to the broader population (Medley et al., 2016; Wanta et al., 2019). Laws that effectively silence instruction about LGBTQ + people, such as Florida’s HB 1557, create messages of exclusion, which give rise to additional societal stressors and amplify existing stressors by instilling a sense of shame around one’s own sexual orientation and gender identity (Berg et al., 2017; Hammack & Cohler, 2011; Herek, 2011). “Don’t Say Gay” laws, and similar legislation, also create a context in which public school teachers and educational staff cannot support students who might identify as LGBTQ + or have questions about their own identities for fear of being in violation of the law. Students with same-sex parents may also feel pressure to avoid discussions of their families in school, and such a silencing effect may produce anxiety related to fear of social rejection.

The creation and amplification of societal stressors along with the inability of teachers and staff to support students may deepen existing mental health disparities and constrain possible avenues of social support. Further, stress created from policies such as HB 1557 can potentially exacerbate stress-related comorbidities, such as cardiovascular disease and hypertension. For example, it is well documented that stress elevates cortisol, and overexposure to cortisol is associated with high blood pressure, heart disease, and stroke (Inoue et al., 2021). These policies may also exacerbate health-compromising behaviors associated with seeking relief from stressors, such as smoking and substance use (Sinha, 2008). Because LGBTQ + populations have elevated rates of tobacco and substance use (Medley et al., 2016; Schuler et al., 2020), these policies may therefore compound existing public health crises.

For people who are minoritized due to their sexual and gender identity and their race and ethnicity, social stressors related to anti-LGBTQ + legislation may be worsened. Existing research has shown that the US’s racially stratified society results in a heightened stress response among people who are minoritized due to their race (Guidi et al., 2021). Over time, this stress response results in chronic stress and elevated allostatic load, leading to deleterious health outcomes and deepened health disparities (Duru et al., 2012; Thomas et al., 2019). For LGBTQ + people of color, the multiple interlocking experiences of oppression based on their sexual and gender identities, and their racial and ethnic identities, may create a heightened stress response with potentially synergistic consequences and result in a syndemic interaction (Kline, 2020).

Interpersonal Consequences: Violence, Lack of Social Support, and Diminished Conversations

More than affecting individual stress, laws like HB 1557 can also have interpersonal consequences. For example, LGBTQ + experience an elevated risk of hate crime violence (Federal Bureau of Investigations, 2019). Laws that send messages of exclusion such as HB 1557 can heighten interpersonal violence resulting from anti-LGBTQ + sentiment since they can embolden people to act on homophobic or transphobic impulses. In instances of homophobic or transphobic violence, LGBTQ + people may be less likely to report crimes to authorities if they feel formal governmental and legal institutions do not support their identities (Miles-Johnson, 2013).

Moreover, silencing conversations about LGBTQ + individuals in classrooms can erode potential social support in schools for LGBTQ + youth and exacerbate bullying and teasing (Day et al., 2020). Social support in schools is particularly important for LGBTQ + youth (Marraccini et al., 2022) who risk family exclusion and household expulsion because of their identities (Perales & Campbell, 2020; Ryan et al., 2009). Indeed, feeling unsupported at school is linked to underreporting bullying and violence among LGBTQ + youth (Russell et al., 2016). Although positive interactions with school officials such as teachers can provide a safeguard for attending a hostile school (Marraccini et al., 2022), laws like HB 1557 prevent positive interactions with school officials from being possible because they silence discussion about LGBTQ + identities. Laws like HB 1557, therefore, threaten the potential for some LGBTQ + youth to find needed social support within their school-based networks, which can be particularly devasting after losing social support in family settings.

The implications of limited social support extend beyond schools and across the life course. Lack of social support is a risk factor for unhealthy relationships in adulthood, such as intimate partner violence (Plazaola-Castaño et al., 2008; Vives-Cases et al., 2010; Wright, 2012). Lack of social support is also associated with negative mental health outcomes, such as depression, anxiety, and loneliness among LGBTQ + youth, which may continue on into adulthood (McConnell et al., 2015). Similarly, the silencing effect created by laws like HB 1557 can have life-course implications since such laws instill shame in LGBTQ + individuals that may then limit their willingness to have honest discussions about their identities as adults (Hammack & Cohler, 2011). This may affect relationships between LGBTQ + individuals and healthcare providers expressed through limited trust and diminished likelihood of disclosing sexual orientation and gender identity to providers (Hudak & Carmack, 2018). A lack of disclosure can result in healthcare needs not being met in a timely manner and overall poorer outcomes for LGBTQ + people.

Broader Policy and Practice Implications

In addition to impacting LGBTQ + individuals, laws like HB 1557 may create additional policy concerns because they create legal precedents around discussions and treatment of an entire group or category of people. Specifically, “Don’t Say Gay” laws create a de facto form of sanctioned discrimination that can lead to additional stigmatizing policies. In other words, laws like HB 1557 can have a snowball effect of legally sanctioned discrimination. Such laws may have spillover consequences into healthcare and health insurance regulations. At the time of this writing, healthcare laws and LGBTQ + identities were already contentious topics; for example, between 2016 and 2020, there were numerous legal challenges regarding whether health providers, insurance companies, and healthcare organizations were legally required to provide the same type of access to care for transgender populations as cisgender people (Lewis et al., 2021). Laws like HB 1557 may create momentum for finding new avenues to exclude LGBTQ + individuals from receiving health services.

Impacts on Public Health Research and Practice

Since public health researchers and practitioners are members of communities impacted by anti-LGBTQ + legislation, laws such as Florida’s HB 1557 also have potential consequences for public health research and practice. For example, these types of laws may have a silencing effect on researchers who are interested in LGBTQ + issues and may create distrust between sexual and gender minorities and the public health workforce. Further, these types of policies may bolster political efforts designed to devalue and weaken public health practice, building on efforts to delegitimize public health that have grown during the COVID-19 pandemic (Abbasi, 2020; Halpern, 2020; Sherling & Bell, 2020). Moreover, these laws may perpetuate a metaphorical “license to discriminate” (Kline, 2019) that can manifest in multiple sectors, including housing and employment, necessitating attention to how anti-LGBTQ + laws may shape well-known social determinants of health. As the field continues to be caught in political battlegrounds, there remains an urgent need for researchers and practitioners to respond to laws like HB 1557 that silence conversations about people with minoritized sexual and gender identities.

Directions for Public Health Scholars and Advocates

Theoretical Directions

Laws that silence conversations around LGBTQ + identities demand attention from public health scholars and advocates. To respond to these laws, several theoretical and methodological tools are needed to inform future research and action. For example, future research must use theoretical perspectives that emphasize the relationship between policies and well-being. Such perspectives can include approaches that make use of multilevel understandings and systems perspectives of health outcomes, social determinants of health perspectives, and perspectives that squarely situate health in a political context, such as political determinants of health (Dawes, 2020). “Political determinants of health” is a theoretical perspective that identifies the interactions between voting, government, and policy as driving catalysts for the social determinants of health that lead to inequities. This perspective considers how governmental institutions, actions, and policies shape the context in which people live and therefore must be addressed to significantly impact social determinants of health (Dawes, 2020).

Beyond well-known health science frameworks, however, social science theories aimed at understanding power, control, and inequality, such as biopolitics (Foucault & Ewald, 2003), can inform future efforts to understand how such laws are efforts to assert power and control over minoritized individuals such as LGBTQ + people. As philosopher Michel Foucault has explained, biopolitics fundamentally considers the multiple machinations of power and control over life, resulting in the single human population being divided in ways that permit some groups to thrive and others to not (Foucault & Ewald, 2003). Further, theoretical lenses used to understand the impacts of these laws must incorporate intersectional understandings of oppression and power that consider the complexity of interlocking sources of oppression, such as race, class, gender identity, sexual orientation, and other socially constructed notions of difference (Bowleg, 2020).

Systems perspectives, ecological approaches, and social science theories of power may not be sufficient to challenge HB 1557 and similar laws. While useful, these perspectives, approaches, and theories must accompany methodological approaches that prioritize social and political action. Accordingly, we argue a need for activist-oriented public health research that squarely focuses on political efforts to advance social justice and health equity for LGBTQ + people. Such efforts cannot be led by researchers alone, however, and must be done in collaboration with community organizations that work to advance social justice. In order to advance health equity for LGBTQ + people, there is a need for political activism that translates public health knowledge into action in collaboration with community partners.

Methodological Approaches

Efforts to center public health knowledge on community members’ lived experiences to combat political forms of division reaffirm the need for methods that emphasize impacted communities as equal partners in research processes. Community-based participatory approaches, for example, are important approaches to advancing research on the consequences of harmful policies targeting sexual and gender minorities. Such approaches may also include the use of implementation science frameworks to systematically disseminate findings to broad audiences and inform the development of political strategies as part of the dissemination approach.

For example, public health scholars and LGBTQ + community partners can collaboratively design research studies with a policy intervention in mind. These collaborations can result in dissemination activities aimed at reversing policy, which can include white papers, policy briefs, infographics, testimonies, requests for elected officials to take specific legislative stances, and draft legislation. Future work can also include impact analyses of legislation (Kovacs Burns & Gordon, 2009) and research which examines the biopsychosocial consequences of anti-LGBTQ + policy using approaches such as cortisol samples (Elzinga et al., 2008; Takai et al., 2004) and telomere length (Epel et al., 2004; Starkweather et al., 2014). Lastly, given the growth of implementation science, particularly around equity in health policy (Oh et al., 2021), there is potential to use implementation frameworks and models in the future to guide the de-implementation of harmful legislation.

Potential Challenges

Combatting anti-LGBTQ + legislation is not without challenges. As researchers, we employ the tools associated with our professions, but researchers remain outsiders to political processes and may have privileges that can protect them from the harms many of these laws produce, including privileges linked to their education, social class, income, and other elements that contribute to their social locations. As such, we must hear, prioritize, and elevate the voices of those most affected by such laws and leverage our privilege to amplify those voices.

Further, given that academic timelines tend to be protracted, it is difficult to rapidly respond to policy. Policy is also difficult to change, and politics are difficult to navigate, and these factors can be additionally complicated by the increasingly political polarization of the USA. As researchers, we assume that people will be persuaded by science and data, particularly data that show policy-related harms. However, this may not be the case, and indeed the COVID-19 crisis in the USA emphasized that compelling scientific data are not always persuasive in guiding action to protect public health (Plohl & Musil, 2021). This may similarly be the case for combatting anti-LGBTQ + policies since some anti-LGBTQ + policies may be intended to stoke political and social divisions as a rallying technique to maintain power. Lastly, given the political focus of this work, finding research funding to support these efforts is challenging, especially in politically polarizing times.

Conclusion

Recently enacted anti-LGBTQ + laws such as Florida’s “Don’t Say Gay” law may have profoundly negative health impacts and require theoretical and methodological approaches to combat policy-created harms. Accordingly, public health researchers and practitioners must combat these efforts through a research agenda that prioritizes reversing policies that negatively affect LGBTQ + individuals and undermine health equity. This research agenda may require theoretical approaches attune to power differences and methodological approaches that squarely focus on disrupting power imbalances. These approaches can guide efforts to address anti-LGBTQ + policy as a political determinant of health that threatens efforts to advance health equity.