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Original Investigation
April 2017

Difference-in-Differences Analysis of the Association Between State Same-Sex Marriage Policies and Adolescent Suicide Attempts

Author Affiliations
  • 1Epidemiology Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  • 2Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
  • 3Division of Adolescent and Young Adult Medicine, Boston Children’s Hospital, Boston, Massachusetts
  • 4Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
JAMA Pediatr. 2017;171(4):350-356. doi:10.1001/jamapediatrics.2016.4529
Key Points

Question  Are state same-sex marriage policies associated with a reduction in adolescent suicide attempts?

Findings  This difference-in-differences analysis of representative data from 47 states found that same-sex marriage policies were associated with a 7% reduction in the proportion of all high school students reporting a suicide attempt within the past year. The effect was concentrated among adolescents who were sexual minorities.

Meaning  Same-sex marriage policies are associated with reduced adolescent suicide attempts.


Importance  Suicide is the second leading cause of death among adolescents between the ages of 15 and 24 years. Adolescents who are sexual minorities experience elevated rates of suicide attempts.

Objective  To evaluate the association between state same-sex marriage policies and adolescent suicide attempts.

Design, Setting, and Participants  This study used state-level Youth Risk Behavior Surveillance System (YRBSS) data from January 1, 1999, to December 31, 2015, which are weighted to be representative of each state that has participation in the survey greater than 60%. A difference-in-differences analysis compared changes in suicide attempts among all public high school students before and after implementation of state policies in 32 states permitting same-sex marriage with year-to-year changes in suicide attempts among high school students in 15 states without policies permitting same-sex marriage. Linear regression was used to control for state, age, sex, race/ethnicity, and year, with Taylor series linearized standard errors clustered by state and classroom. In a secondary analysis among students who are sexual minorities, we included an interaction between sexual minority identity and living in a state that had implemented same-sex marriage policies.

Interventions  Implementation of state policies permitting same-sex marriage during the full period of YRBSS data collection.

Main Outcomes and Measures  Self-report of 1 or more suicide attempts within the past 12 months.

Results  Among the 762 678 students (mean [SD] age, 16.0 [1.2] years; 366 063 males and 396 615 females) who participated in the YRBSS between 1999 and 2015, a weighted 8.6% of all high school students and 28.5% of students who identified as sexual minorities reported suicide attempts before implementation of same-sex marriage policies. Same-sex marriage policies were associated with a 0.6–percentage point (95% CI, –1.2 to –0.01 percentage points) reduction in suicide attempts, representing a 7% relative reduction in the proportion of high school students attempting suicide owing to same-sex marriage implementation. The association was concentrated among students who were sexual minorities.

Conclusions and Relevance  State same-sex marriage policies were associated with a reduction in the proportion of high school students reporting suicide attempts, providing empirical evidence for an association between same-sex marriage policies and mental health outcomes.