Association of State Conscientious Objection Laws and Sexual Minority Population Health

Abstract Introduction The legality of denying health services based on sexual orientation is actively being litigated in the United States. Currently, ten US states have passed conscientious objection laws, allowing for denial of health services based on sexual orientation. The objective of this study was to estimate the association between state conscientious objection laws and changes in health service use and health status among sexual minority adults. Methods 2016–2018 Behavioral Risk Factor Surveillance System (BRFSS) data from adults ages 18-64. We used a difference-in-difference-in-differences linear regression analysis with state and year fixed effects to compare outcomes in two states with conscientious objection laws with six states without such laws. We compared sexual minority adults to heterosexual adults, controlling for binary sex, age categories, race, and ethnicity. The primary exposure was living in a state that enacted state-level conscientious objection laws in 2017. Outcomes included health service use (first-time HIV testing, routine checkup, and reporting a usual source of care) and health status (self-rated health, and frequent mental distress). Results The sample included 109,220 adults, 93,908 in states without conscientious objection laws and 15,312 in states with conscientious objection laws. Of the total sample, 5,076 (weighted 5.5%) identified as sexual minority. Among sexual minority adults, conscientious objection laws were associated with a 9.3 percentage point increase in no lifetime HIV test compared to states without conscientious objection laws (95% CI: 3.3, 15.3; p=0.008), a 28% relative increase and a 9.6 percentage point increase in fair or poor self-rated health in states with versus without conscientious objection laws (95% CI: 5.1, 14.2; p=0.002), a 71% relative increase. Conclusion Conscientious objection laws were associated with more sexual minority adults reporting no lifetime HIV test and being in worse health. Policy Implications Approximately 20% of the U.S. LGBTQ+ population now live in states with conscientious objection laws. Federal non-discrimination statutes are needed to ensure adequate access to health services for LGBTQ+ populations.