Coronavirus: Transgender people 'extremely vulnerable' during lockdown
International transgender rights groups are warning global coronavirus lockdown restrictions have led to trans people being denied healthcare. Many have had surgeries delayed, and some are struggling to access hormone therapy and counselling services.
Gender reassignment surgeries have been delayed globally as a result of coronavirus - with elective procedures stopped to expand capacity for intensive care because of the pandemic.
Although hormone treatments are still available to many in the West, trans-rights groups in East Africa warn that may not be the case for transgender people in other continents.
"Transgender people are already an extremely vulnerable group," says Barbra Wangare, the Executive Director of East Africa Trans Health & Advocacy Network (EATHAN), "and support has historically never been a priority - even among the LGBT community. Coronavirus will only expose more of these vulnerabilities.
"We are hearing from people who say they fear they are detransitioning due to lack of access to medical care. This puts them in an extremely fragile emotional state."
Transgender people are about twice as likely to take their own lives as other LGBT people, according to a 2017 Lancaster University study, 'Suicide in Trans Populations'. The paper, which looked at several peer reviewed studies, suggests lack of health access adds particular pressure to the trans community.
The BBC has spoken to two transitioning men in Kenya and in the US about what coronavirus lockdown has meant to their transitions.
Mauricio Ochieng, 30, Kisumu state, Kenya
Mauricio travels seven hours on a bus to Nairobi to collect his testosterone injections. It's a journey he's been making for over a year. It's worth it.
"With the injections my body has started changing, I look less 'feminine', my voice is deeper and I'm growing a beard," he says. "I was finally on the way to becoming myself. I am a man. I was never a woman."
Growing up in rural Kenya, about 350km from the capital Nairobi, Mauricio knew he was different. He has more than 150 cousins and couldn't relate to any of them.
"I was the black sheep of the family."
He knew that he was not a girl, despite his body. His parents believed he was a lesbian. That was bad enough, they said, but it was something they understood. When he told them that he was a man in a woman's body, they made him leave the family home.
Mauricio was 16 and homeless. He was sexually assaulted multiple times. Just over a year later, he fell pregnant from one of the rapes. People called him a "chokora", a slur for a street beggar.
He went to his mother's house and said: "Please don't make me give birth in the street like a dog."
She let him come home.
Mauricio's daughter was born in 2007. He worked at the local market, buying and selling shoes.
In 2018 he decided to begin his transition. Testosterone injections cost around 1,200 shilling per dose (about £9) - which is a day's work.
The 14-hour round trip each month to collect his medication felt like a huge achievement. Mauricio was saving up for top surgery: to have his breasts removed.
Then coronavirus reached Kenya, and soon lockdown restrictions followed.
Mauricio does not have his next supply of testosterone.
"I'm having sleepless nights, depression," he says. "What will happen if I cannot have access to my medication? What will all this pain have been for?
"I am a trans man in a transphobic country. If I don't get my medication what will happen to my body - it is already changing. Will I look abnormal? Who is going to fight for us to be heard in this chaos?"
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Liam T Papworth, 30, Chicago US, was the first openly transgender man to recruit into the US army
2020 was going to be the year that Liam had his phalloplasty - and completed his transition to a male body.
"A phalloplasty is essentially the surgery where a female to male trans person would get his penis," he says, jokingly flippant, to temper the years of frustration, "to put it in the most watered down way."
The coronavirus pandemic delayed Liam's surgery until at least the end of 2021, as he is no longer seen as a medical priority.
"It's a major blow because I had put my entire life on hold to get this surgery.
"I was supposed to be going back to school and I decided not to so that I could get my surgery."
The surgery is the final operation in an arduous transition for Liam that began when he was 19.
As a child, Liam didn't feel like a girl. He remembers arguing with his aunt at his father's funeral - insisting that he should be able to wear "boy's clothes" and not the dress they had chosen.
After three psychological therapy sessions, at 19, Liam was prescribed testosterone injections. His periods stopped, his body felt more like a home.
But it was still a long, frustrating period of bureaucracy, he says.
Gender reassignment varies state to state in the US. Doctors can refuse patients based on private medical insurance conditions.
In 2016, age 25, Liam had a bilateral mastectomy - both his breasts removed. It was day surgery, and he was out of hospital within 12 hours.
Life changed. Liam could finally go to the swimming pool with trunks, his shirt off. He competed in triathlons, ran 15km races. It was liberating.
Despite a 2017 policy by the White House to ban transgender military service, some lower courts placed injunctions on the ban, meaning that on 23 February 2018 Liam became the first openly transgender recruit to enlist into the US army.
Liam's name was not released to the press at the time. He was discharged on medical grounds the same year - after a severe injury.
By 2019, the rules changed again, when the US Supreme Court lifted some of the injunctions. Liam felt he couldn't rejoin.
That's when Liam decided to proceed to the next stage of his transition.
In October 2019, he had a total laparoscopic hysterectomy, where both his ovaries were removed.
Liam had to stop testosterone injections for weeks beforehand. The surgery meant he stopped producing oestrogen. Liam became depressed, feeling his life plans were on hold.
Yet hope was still there, he was only months away from the final procedure: the phalloplasty.
"It meant everything to me," he says. "I could put all this behind me. I could actually move on."
There were administrative issues though. Initially the hospital said Liam's insurance did not cover a phalloplasty. Illinois state representative Greg Harris intervened to ensure Liam was eligible for the procedure. But now the insurers say the pandemic means Liam needs to reapply when a new surgery date is set.
"Trans medical rights have never been a priority in the medical world," Liam says, "which can be incredibly frustrating.
"Yes, coronavirus is a global health crisis. But the mental health of trans people is too.
"I understand that of course healthcare providers need to make tough calls and prioritise during this time. It would be nice to be a priority, just once."