The consequences don’t end at mental health. Gay, lesbian, and bisexual people who experienced homophobic language get more headaches216 and chronic diseases, and they are in worse overall health. (HIV, which weakens the immune system, may explain some, but not all of these disparities. Gay women, who have a lower risk for HIV than gay men do, are also less healthy than straight women, and among gay men, some of the disparities persist after controlling for HIV status.)217

It’s not clear whether these mental and physical health issues arise because LGBT people have to hide their true identities or because they face prejudice after coming out. A study that followed HIV-positive gay men for nine years found that the infection progressed more rapidly among those who were in the closet.218 But another study that sampled the saliva of gay and bisexual men throughout the day found those who were out to their workplaces had higher levels of cortisol, a stress hormone.219 The study authors weren’t sure why this happened, but they suggested it might have been because the out men were experiencing more discrimination at work—or perhaps because they were just anticipating it.

This is what this heightened anticipation looks like, from another of the transgender women interviewed by researchers for Transgender Health in 2016:

Any time I’m in the presence of someone who knew me before—so, past family members, past friends, anybody like that—it’s almost like every muscle in my body is in a heightened state of alert and my blood pressure, I can almost feel it pumping…I’m ready for them to say the wrong pronouns or use the wrong name, or speak to me in some negative way even if they haven’t done it or aren’t going to. Usually, by the time that situation is over, whether or not anything bad happened, I’ll just burst into tears or just decompress emotionally after it’s done because I’m so ready to be hurt, expecting to be hurt.

The distress, for trans people, may come from realizing that some people will continue to treat you as though you never transitioned. In some cases, the authors of one 2005 study wrote, “the consequences of disclosure can be more harmful than those of inhibition.”

Throughout my reporting, I met several trans people for whom transitioning resolved the stress of gender dysphoria. The stress of standing out, meanwhile, persisted.

Vivienne, Part I

Before Vivienne Ming became Vivienne Ming, a mother, scientist, and entrepreneur, she wasn’t sure she wanted to be, period.