When we talk about mental health, we need to talk about how stress is actually killing American women

May is Mental Health Awareness Month.

There is an expression, attributed to some unknown source, that I’ve seen posted in more than one office cubicle of a female coworker: “A diamond is just a piece of charcoal that handled stress exceptionally well.” It reads innocently enough, but it implies something a lot less shiny. As women, we want to have it all — a career, a fulfilling social life, a satisfying sex life, a healthy family. And we are told that we can have it all if we just work hard enough, if we can just sustain the pressure long enough to become dazzling gems. Often, that means taking on extra responsibilities at home or at work, while sacrificing basic needs, wants, and important self-care practices. For many women, it can also mean taking on an overwhelming amount of stress, something that can seriously affect our health and well-being.

In fact, they say stress can kill you, and Mental Health Awareness Month is the perfect time to shine a light on exactly who it is killing: women.

Every 80 seconds, approximately one woman dies from cardiovascular diseases or stroke. According to the Centers for Disease Control and Prevention, heart disease is the leading cause of death for women in the United States. In fact, 90% of women have at least one risk factor for heart disease or stroke, including risk factors related to mental health. The statistics are dreary, but what is even more upsetting is the fact that 80% of heart disease and related illnesses can be prevented by lifestyle changes and education. But in American culture, women are expected to take on stressors that make for the complete antithesis of a heart-healthy lifestyle.

In the United States, women are more likely to experience stress than men, and it’s largely a societal problem. Women are just expected to do more, and to do it without complaining. The stressors they experience run the gamut, but the most common among women include financial, familial, marriage, and career stress. These are all things men face as well, but almost always to a lesser degree.

It is not that women always experience more stress than men, though women are more likely to report having higher levels of stress than men. More than anything, the type of stress they experience — and the physical and emotional symptoms of that stress — are very different.

“Stress often affects women differently from men because women are often pressured more than men to ‘have it together,’ but not [have it together] more than men,” says Shani Graves, LMHC, a licensed psychotherapist in New York. “Women are pressured into believing that they are required have great careers, while also learning to play small amongst men. They are pressured to settle down in marriages and have children, all while chasing their dreams, or at times asked to stop chasing their dreams.”

Women are expected to land the great job, nag the ideal partner, maintain meaningful friendships, and keep a healthy body that adheres to narrow beauty standards. But we live in a patriarchal society, so this implied American Dream is vastly different from many women’s realities. Still, women struggle to meet societal expectations that are, in the end, more harmful than helpful.

According to Graves, it’s this cultural pressure on women’s minds and spirits that causes an intense level of stress. Worse, women don’t know how to cope with that stress because they’ve been taught that self-care is a privilege, not a requirement.

Men benefit from a culture that promotes stress relief, while womanhood comes with the expectation that, like a diamond, you can shine underneath all that pressure. (Just think about how fathers are never guilted for focusing only on work and financial stability, while women are pressured to raise their families and provide for them financially.)

“Stress tends to be internalized for women and externalized for men,” explains Rachel Oppenheimer, a licensed clinical psychologist and owner of Upside Therapy and Evaluation Center. “Men have general reputations of having outlets for their stress. They go blow off steam while women are expected to stay unflappable, despite the same pressures.”

In the context of work, family, and friendship, women are held to a higher standard than men. They are expected to show up for work, be home for dinner, make time for friends on the weekend, and maintain a stress-free appearance. For men, expressing stress is a kind of status symbol (like blaming their aloofness or anger on stress caused by their important job). Oppenheimer explains that, for women, revealing stress is viewed as a weakness.  She continues, “Women have grown up with the implicit lesson that their emotions are causing them to be vulnerable, and so they are less likely to express their very valid stress experience.”

Societal pressure plays an even greater role in the lives of women of color — Black women in particular — who are at an even higher risk of stress-related death than men and Caucasian women.

According to the CDC,  7.6% of African-American women suffer from coronary heart disease, making it their leading cause of death. Racial and gendered stress are largely to blame.

“Within the Black community, women are perceived as superhuman. They are taught to protect the Black man, protect their children, protect their community and if there is time, maybe they can take care of themselves,” explains Graves. “Black mothers struggle with needing to let go of burdens and mental baggage that happens due to racism and sexism, all while being caretakers to children that depend on them. Self-care…can be perceived as being selfish, because it takes away time from ‘responsibilities.'”

Recent studies have also revealed that Black mothers are dying at alarming rates. Chronic stress takes a physical toll on Black women during their pregnancies and childbirth, due in part to the discrimination they face when seeking medical attention, as well as the racial and economic barriers they’re forced to jump over just to access it. Soon after giving birth, the stress can become even more dangerous, which is one of the reasons that Black mothers die three to four times the rate of white mothers.

Mental health has a role in every woman’s stress levels, regardless of race, and stress has an equally huge role in women’s heart health.

Until we address the intense pressure facing American women, especially women of color, and until we can start teaching women and girls how to cope with (not hide) their stress, they will continue to be at risk of heart disease and death.

“As a culture, we can begin to normalize self-care,” Graves suggests. “If self-care and positive mental health is seen as something needed, then more women will feel inclined to engage in it.”

Mental Health Awareness Month is the perfect time to start.