Being LGBTQ is not exactly getting easier by the day. The mental and physical toll of living in what I’m finding to be an increasingly anti-LGBTQ climate creates a toxic amount of stress. It might sound strange to call 2018 a time of intolerance but discrimination in healthcare settings are endangering lives in the community and, a recent study shows that for the first time since 2014, less people are comfortable with LGBTQ people as a group. This can create “minority stress”—a term coined by Ilan Meyer in his research—otherwise known as chronically high levels of stress felt by stigmatized groups of people. To pile on, these groups don’t tend to see the doctor on a regular basis for their healthcare needs.

Minority stress signifies the emotional weight that marginalized people face as they interact with a world that’s not designed for them, says Richard Greene, an associate professor in the department of medicine at New York University who works predominantly with LGBTQ patients in his practice. “It’s the kind of thing that can impact you if you are actively discriminated against or it’s the kind of thing that we’re programmed as LGBTQ people [to know] that may happen to us,” he says. For example, if a doctor has ever said something negative about you being LGBTQ—even unintentionally—it will negatively affect how you interact with the healthcare system in the future.

“When I first found out I was positive, the very first infectious disease doctor I saw treated me like an animal. I was terrified, and he was cold and harsh,” says Todd Calton, who lives in Charlotte, North Carolina and was diagnosed with HIV in 1995. “When I’d go to regular doctors for different illnesses, I’d keep a secret so that I wouldn’t have to face that. Whether it was true or not, the first experience had a huge impact on how I dealt with it.” While this experience happened decades ago, it still casts a shadow over healthcare for Calton.

With intersectional identities—being black and queer, for example—this stress can increase, Greene says. “If you’re a black lesbian, for example, you have to deal with not just homophobia but sexism and all of those kind of things and that just gets worse for you in terms of how you approach healthcare.”

When LGBTQ people live with that kind of stress and fear because of one or multiple identities, Greene says, it can increase their stress hormone levels. It can also provoke or exacerbate risk-taking behaviors among LGBTQ people, compared to non-LGBTQ people—greater tobacco and drug use, in particular, which can worsen common health conditions, a few of which are listed here.

Heart health is worse for LGBTQ people than for non-LGBTQ people

A new study found that more LGBTQ people had less than ideal heart health compared to non-LGBTQ people: Among adults ages 20 to 49 in their participant set, 45 percent of gay men and lesbians had “intermediate or ideal cardiovascular health” compared to 60 percent of heterosexuals and 56.2 percent of bisexuals. Transgender people don’t appear to have been part of the study, or at least didn’t self-identify.

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“LGBTQ people are at an increased risk for the precursors to coronary artery disease and heart diseases,” says Rhett Brown, a primary care physician in Charlotte, North Carolina who predominantly serves an LGBTQ population. Brown notes how many of his patients, regardless of sexual orientation, come into his office complaining about fatigue, chest pain, tightness or heaviness with exertion. But the lifestyle choices of his LGBTQ patients are often poorer than his non-LGBTQ patients. “We have the marketing image of the young gay men, cut, on the treadmill, but actually, that body image—like the thin women on _Cosmopolitan—_is not the reality.”

As a queer woman, I can understand that concept. During one visit, my doctor told me he noticed that I was gaining more weight each year, and while this was true, I was reluctant to tell him why: I had become increasingly more visible as a queer woman, and began running my own business. Eating a box of cookies at my desk, sleeping less than six hours a night, and not making time for exercise were all habits that were beginning to manifest.

Recent research has also shown that transgender women on estrogen therapy are at an increased risk of cardiovascular events. Weighing the risks of hormone therapy against feelings of dysphoria can be potentially dangerous. “You think of the downfall of not providing hormone therapy,” says Hansel Arroyo, director of the transgender psychiatry fellowship and assistant professor of psychiatry at Icahn School of Medicine at Mount Sinai in New York. “The downfall is their dysphoric symptoms will worsen and the suicide rate goes up to 41 percent if they’re not being given the support and care that they need.”

My fiancee, Lara Americo, 33, knows this all too well: She’s been off hormone therapy for almost one year in the hopes she can create sperm that will eventually meet my egg, but has been vocal about how hormone replacement therapy is more of a priority than the potential for heart issues in trans women. “If [trans women] had to get off estrogen, it doesn’t matter what heart risks or health risks there are when you can’t be yourself,” she says. “If you can’t have your body, what does the heart health risk matter if you can’t have a body that reflects you?”

LGBTQ people experience higher rates of depression

LGBTQ people are three times more likely to have a mental health condition such as major depression and/or generalized anxiety disorder than the general population, which can affect how they approach their physical health. Specifically, 41 percent of transgender people, through a combination of experiencing transphobia, racism, and poor living conditions, have attempted suicide.

Living in a world that feels uncomfortable, or even hostile toward you can have serious mental and physical health consequences. “If you have had to live in an environment where you had your parents were supportive, you had a faith community, [but] you had to hide yourself, you got the impression that you are less than or you’re not worthy or being who you are is somehow wrong, than that leads to greater rates of depression,” Brown says. “When you’re depressed, you don’t take care of yourself. You don’t make the effort to exercise, eat healthy, meditate, [and] you may not have the ability to choose well.”

Toward the end of my illustrious paralegal career before I became a full-time writer, the pressure to hide elements of myself, even at the doctor’s office, almost destroyed me. Having to put on the beige heels, form-fitting dresses and pearls started to make me feel self-destructive. I’d keep Famous Amos cookies in my filing cabinet and pop one or five while listening to co-workers say call certain women “dykes,” and and wondering if I’d be next. I’d watch the closeted legal admin pretend every day that she wasn’t a Hawaiian shirt-wearing version of K.D. Lang. The dissonance between who I was and where I actually was in life (compounded with having to watch someone else with the same problem) definitely affected my psyche.

LGBTQ people are at a higher risk for cancer than non-LGBTQ people.

Per the National LGBT Cancer Network, LGBTQ people have an increased risk of being diagnosed with cancer compared to non-LGBTQ people—the stat is attributed to a combination of behaviors such as tobacco use and socio-economic factors (the minority stress mentioned earlier, largely).

There’s also a biological component that could apply to non-LGBTQ women as it does to lesbians, bisexual people, and transgender people when it comes to breast cancer. Lesbians and queer-identified women who haven’t given birth to their own biological children before the age of 30, as archaic as it sounds, have an increased breast cancer risk.

“Childbirth is protective against ovarian cancer and breast cancer,” Brown says. “If you let the body do what it’s ‘designed’ to do, it’s happier. If the breast never goes through the full process of changing—producing milk and all that—that whole process lowers the risk of breast cancer.” Of course Brown doesn’t suggest every woman go get knocked up to prevent getting cancer, but it does play a factor in the overall cancer risk of women.

What can LGBTQ people do to fight these grim stats?

Since most of these conditions can be treated if caught early, or at least treated on a regular basis, it’s key for LGBTQ people to find healthcare providers that allow them to completely be themselves. LGBTQ people, Greene says, need to feel safe at the doctor’s office and healthcare systems need to have reliable systems that track gender identity and sexual orientation to know how they’re serving the LGBTQ portion of their patients.

This can mean all the difference for LGBTQ patients. Greene says he loves taking care of his LGBTQ patients and feels a kinship with them. One of his patients, who is in his 70s, recently discussed his sex life at an appointment, which is a testament to the patient’s comfort level. “He teared up at the end of the visit and gave me a really big hug," Greene says, "and said he would never have had imagined that he could have a conversation like this with a doctor."