COVID-19 and Trans Healthcare: Yes, Global Pandemics are (also) a Trans Rights Issue By Gen Eickers, University of Education Ludwigsburg, Germany Abstract Trans healthcare and thus trans people have been severely affected by the COVID-19 pandemic. Trans people's healthcare situations have turned out to be so vulnerable in this crisis because they have been precarious to begin with. There are multiple ways in which trans healthcare has been affected: Surgeries and other procedures have been cancelled or postponed, and mental health services have been paused or moved online. This raises ethical questions around discrimination against trans people in the healthcare system. This article argues that cancelling trans surgeries and procedures in the COVID-19 crisis is made possible through an understanding of trans healthcare as non-essential. The article explores how trans healthcare in particular has been affected by the pandemic. 1 In many nations worldwide, the current COVID-19 pandemic has placed an additional burden on trans healthcare. Trans people constitute one of the demographics that is significantly affected by the pandemic. Many trans healthcare services have been cancelled or halted, and it is unclear if or when they will be accessible again. For example, gender-affirming surgeries have been halted so hospital beds can be saved for COVID-19 patients, hormones might not be available in some places due to shortages in production, consultation with psychiatrists or therapists might be on hold, and consultation with new patients for hormone replacement therapy (HRT) might be postponed. When certain medical procedures are getting re-classified as non-necessary, the effects of the pandemic are already larger than what is immediately obvious. This article will explore trans healthcare as one of the many ethical challenges the COVID-19 pandemic presents. 2 There are many trans rights issues when it comes to the COVID-19 crisis, for example: rights for trans sex workers who have lost their income, rights for homeless trans people, rights for trans people who do not have matching documents and are more likely to be confronted by police for being on the street, rights for trans people who need to stay home in unsafe environments, and legal recognition of trans people (this very basic right is currently under attack in Hungary: this is a result of how the pandemic is enabling governments to rapidly change policy).1 These are all important topics that must be properly addressed. The focus in this article, however, is on trans healthcare and the social and moral rights of trans people regarding trans healthcare in the COVID19 crisis. Exploring the effects of the crisis on trans healthcare in an academic article can help to shed light on the situation for trans people in this crisis. Knowledge around trans people's realities is often marginalized. It is important to acknowledge that gender has an influence on people's lived realities in order to understand the overall impact of situations like the COVID-19 crisis. 3 This article explores the ways in which trans healthcare has been affected by the COVID19 pandemic and analyzes how the pandemic highlights flaws in trans healthcare that have been present long before the crisis. The article especially takes issue with the re-classification of trans surgeries and procedures as non-necessary and argues that this re-classification is based on the idea that trans surgeries are mere aesthetic surgeries that are not essential. What's the Issue with Trans Healthcare During the Covid-19 Pandemic? 4 Trans people often already find themselves in precarious healthcare situations (Appenroth and do Mar Castro Varela, 2019). This includes being denied treatment or having to wait a long time for hormones or surgeries. Trans people also have to provide several proofs of identity in order to be able to receive treatment, and they have to undergo several (psychological and physical) examinations before starting hormones or before getting surgeries. 5 Trans people are often met with reluctance when they seek medical or healthcare treatment of any kind. This reluctance can include transphobic attitudes or denial of treatment (Bauer et al. 2009, Bradford et al. 2013, Beemyn & Rankin 2011). The degree to which this is the case depends, for one, on how familiar the doctor and medical staff they are seeking treatment from are with trans people. Trans people are less likely to go to the doctor when they are sick since doctors' offices and institutions of the health care system in general are spaces where trans people face discrimination and lack of knowledge on a regular basis (Bauer et al. 2009; Bauer et al. 2014; Bradford et al. 2013; Sperber et al. 2005). 1	Novak, Benjamin. "Hungary Outlaws Changing Gender on Documents After Birth." New York Times, May 28, 2020, www.nytimes.com/2020/05/28/world/europe/hungary-transgender-law.html, Accessed: June 09, 2020. 6 The degree to which this describes the lived reality of many trans people differs depending on the country or region or city one lives in. In Germany, for example, trans people who transition medically need to provide proof of their trans identity at various stages into medical transition. In order to undergo HRT, for example, the trans person in question is typically required to have a letter from their therapist or psychiatrist confirming their being trans. This does not describe a legal requirement, however. It reflects the practice doctors make use of when being confronted with the wish of a trans person for medical transition (DGfS 2019). 7 A consequence worth mentioning that follows from what has been described so far is that trans people are more likely to be discriminated against by medical staff and in hospitals in general, and thus also in the case that they are infected with COVID-19. This discriminatory treatment disproportionally affects BIPOC trans people.2 The disproportionality is not restricted to trans people, of course. However, Black trans people are more likely to have already existing and often untreated health conditions (Smedley et al. 2003, Xavier et al. 2005). This is the case since Black trans people might have been avoiding medical care due to experiences of discrimination (Smedley et al. 2003, Xavier et al., 2005, Cicero et al. 2019, Salerno et al. 2019). A study by Kattari et al. (2015) found that Black trans people and trans People of Color experience higher rates of discrimination in healthcare. They found "high rates of discrimination against transgender/GNC individuals when they are trying to access doctors and hospitals, emergency rooms, and ambulances/EMTs, with significantly higher rates of discrimination experienced by those individuals who are also people of color" (74). Black people might also have been financially unable to seek medical care due to being in precarious economic situations and due to other factors like unclear insurance coverage, regional variation in care, and even quality of care within the same institution.3 Background of Trans Discrimination in Healthcare 8 Historically, trans healthcare is built on a pathologizing understanding of trans identities (Sauer & Nieder, 2019). The ICD-11 (International Statistical Classification of Diseases and 2 Cineas, Fabiola. "Covid-19 is disproportiantely taking Black lives." Vox, April 8, 2020, www.vox.com/identities/2020/4/7/21211849/coronavirus-black-americans, Accessed: May 13, 2020. 3 Badgett, Lee M.V. et al. "LGBT Poverty in the United States. A study of differences between sexual orientation and gender identity groups." October 2019, williamsinstitute.law.ucla.edu/wp-content/uploads/National-LGBT-PovertyOct-2019.pdf. Accessed May 10, 2020. Related Health Problems, 11th revision) is the first to hold a fairly de-pathologized account of what it means to be transgender. The ICD-11 speaks of gender incongruence but does not classify being transgender to be a disorder any longer (World Health Organization 2018). Furthermore, it does not understand being transgender as a rigorous transition from female to male or male to female but includes more flexibility and includes non-binary identities explicitly. The ICD-11 was passed in 2018 but will probably not be in legally binding effect before 2022. Before the ICD-11 will be considered legally binding, the ICD-10 remains in place. Before the ICD-11, trans individuals have been and continue to be pathologized under the label "transsexualism" (ICD-10) and further labels that all belong to the ICD-10 category of "gender identity disorders" (World Health Organization 2004). That is, to be transgender has been considered to be a (mental) disorder. Thus, to be transgender has been highly pathologized. 9 On the basis of the conceptualization of trans people as people suffering from a disorder, medical practices have emerged that have led to gatekeeping and to further pathologizing trans people. These practices can look as simple as interrogations or comments from a medical professional that a trans person goes to in order to receive hormones, but they might also be as complex as interfering with a relationship between a therapist and their patient that has been helpful to the patient and non-discriminatory up until the patient came out as trans. 10 Trans persons are often asked by cis persons to explain why using the new pronouns and new name is so important and to explain other things related to being trans. Asking these questions is based on cis privileges; the practice of asking such questions is cis-normative. As Serano notes, There is a straight line that connects inadvertent pronoun slips, [...]and trans people who are beaten, even murdered, while their assailants claim that they are somehow victims of the trans person's "deception." These acts may differ greatly in their severity, but they all communicate the exact same message: that trans people's gender identities, expressions, and sex embodiments are not deserving of the same rights or respect that are regularly extended to our cisgender counterparts. (2009, 4) That is, in contrast to the cis-normative conviction, the questions mentioned are anything but value-free. They are permeated by values and normative signals that are projected onto the trans person being asked. Questions and statements of this type are instruments of discrimination. Structurally institutionalized cis-normativity is also commonly referred to as cisgenderism or cissexism, both of which terms inhabit the idea that cis-normativity can be discriminatory: cissexism – forms of sexism that construe trans people's gender identities and expressions as less legitimate than those of cis people (those who are not trans). Cissexism-or as some describe it, transphobia – can be seen in how individuals, organizations, and governments often refuse to respect trans people's lived experiences in our identified genders/sexes; in the discrimination we may face in employment or medical settings; and in how trans people are often targeted for harassment and violence. (Serano 2013, 45) 11 The obstacles in trans healthcare are part of a system that repeatedly fails trans people, since these obstacles contribute to denying trans persons their personhood by way of rejecting their knowledge about their own personhood. Bettcher calls this basic denial of authenticity, which she further classifies as a kind of transphobia (Bettcher 2006). She defines basic denial of authenticity as "the kind of transphobia whereby trans people are viewed contrary to our own selfidentifications" (Bettcher 2006, 204). Physical Health: Cancellation of Surgeries and Other Procedures 12 On March 12th 2020, the German government declared that surgeries that are not necessary or urgent should be postponed indefinitely.4 This was not a decision specific to Germany. Rather, surgeries were declared unnecessary and to be postponed in many nations worldwide.5 By (re-) categorizing some surgeries as unnecessary, governments hoped that hospitals could prepare for the expected increasing demand for intensive care and ventilation capacities for the treatment of patients with severe cases of COVID-19. That is, surgeries that are not considered 'necessary' or 'urgent' are halted for the time being and postponed to an unknown date. 13 These rulings affect trans people since this includes smaller and bigger gender-affirming surgeries (e.g., hair removal, mastectomy, genital reassignment surgeries). These are processes and surgeries with long lead times. The application process alone for top surgeries in Germany, for example, can range from two to six months. In addition, in order to be eligible for trans 4 "Sozialkontakte vermeiden, Ausbreitung verlangsamen" ["Avoid Social Contacts, Slow the Spread."], Die Bundesregierung, March 12, 2020, www.bundesregierung.de/breg-de/themen/coronavirus/mpk-1730186, Accessed: June 11,2020. "Hunderttausende Operationen wegen Corona verschoben" ["Hundreds of Thousdans of Surgeries postponed due to Corona."], MDR aktuell, May 16, 2020, www.mdr.de/nachrichten/politik/regional/coronahunderttausende-verschobene-operationen-100.html, Accessed: June 11, 2020. LSVD, "Corona und Lesben, Schwule, Bisexuelle, Transund Intergeschlechtliche Menschen. Wie sich Covid19 auf das Leben von LSBTI auswirkt." ["Corona and Lesbians, Gays, Transgender, and Intersex People. How Covid19 affects the lives of LGBTI."], www.lsvd.de/de/ct/2067-Corona-und-Lesben-Schwule-Bisexuelle-trans-und-intergeschlechtlicheMenschen, Accessed: June 11,2020. 5 "Tens of millions of surgeries are being postponed as a result of the pandemic.", The Economist, May 18, 2020. www.economist.com/graphic-detail/2020/05/18/tens-of-millions-of-surgeries-are-being-postponed-as-a-result-ofthe-pandemic. Accssed: June 11, 2020. surgeries, one typically needs proof of at least 1.5 years of therapy and six months of hormone replacement therapy (HRT). That is, needing to wait two years for a gender-affirming surgery is not an exception (Deutsche Gesellschaft fuer Sexualforschung (DGfS) 2019). Surgeons who perform those surgeries are rare and usually have long waiting lists as well. All of these requirements and factors make a fast proceeding in trans healthcare impossible. Trans people typically have to wait a long time to get the treatment they need. Now, in times of COVID-19, things look even more difficult. 14 For a trans person taking hormones or undergoing surgery, these procedures are experienced as necessary in the most literal sense. The decision to take hormones or undergo surgeries is based on a need. For many trans people, these are life-saving procedures (Bailey et al. 2014). For most, hormones and surgeries are life-altering and can greatly reduce gender dysphoria (WPATH, Murad et al. 2010).6 Green (2004) makes clear that when trans people undergo surgeries, "the purpose, usually, is to facilitate our being perceived socially by others as the men or women we know ourselves to be, even though we may acquire or retain physical differences from other men or women in the process" (90). Being perceived as the gender one is can be an essential step in reducing gender dysphoria and can help in navigating social contacts. 15 Trans surgeries are not comparable to aesthetic or cosmetic surgeries that are pursued in order to move closer to an aesthetic ideal. Trans surgeries are not based on a wish for solely aesthetic change. In any case, the analogy would not undermine the claim that trans surgeries are necessary. Those who conceive of trans surgeries as aesthetic should bear in mind that some aesthetic surgeries are necessary for well-being. Trans surgeries, like reconstructive surgeries, are necessary for some trans people for coping with social environments that can be otherwise hostile and threatening. Trans surgeries and other medical processes are needed for those who pursue them as these surgeries can be of help for a trans person moving around in a cis-normative world. That is, oftentimes trans people feel a strong need to 'pass' – i.e., to be perceived as the gender they are or as the gender they want to be perceived as.7 6 "Gender dysphoria refers to discomfort or distress that is caused by a discrepancy between a person's gender identity and that person's sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics)." (WPATH, 5) 7 The suggestion here is not that being trans means wanting to be perceived as a certain gender. However, this can be part of someone's trans experience. For example, some non-binary folks want to be perceived as male or female rather than „queer/ non-binary / other" when they move around in the world – this might be due to a need for safety or due to the need to move around without being stared at or noticed. 16 Passing can be of high importance to trans people since it protects them from being the recipient of violence. As an AFAB trans person, one might pass as a woman before or without hormones (and surgeries), and with hormones (and surgeries) one might pass as a man.8 The risk of direct violence is mitigated for some people when they pass. This is often especially important for trans women since they are the most vulnerable to and affected by transphobic violence. When someone is suspected to be a trans woman, rather than a cis woman, they are at a greater risk of being attacked (Bettcher 2007, Stoljar 2018, Turner et al. 2009).9 17 The felt need for trans surgeries is not simply a matter of navigating the social world. As noted, trans surgeries can also help alleviate gender dysphoria or body dysmorphia and thus might ultimately lead to an improvement of associated mental health issues (such as depression and anxiety). Depression is a life-threatening condition, and rates of self-harm are alarmingly high in the trans community (Marshall 2016). Trans surgeries are not about achieving to have an aesthetically pleasing body in the cis-normative sense. This understanding of trans surgeries needs to be changed: trans bodies – even after surgery – will typically not manage to comply to cisnormative ideas of beauty. Rather, trans surgeries are mostly about trying to have a (comfortable) body at all. Green (2004) notes, "Most of us are not seeking perfection when measured against external stereotypes; rather, most of us are seeking an internal sense of comfort when measured against our own sense of ourselves" (90). When deemed unnecessary and not urgent, trans surgeries are equated with all aesthetic or cosmetic procedures. That equation itself can be harmful because it perpetuates transphobic attitudes and failures of understanding. 18 One might ask, why is it ethically questionable that trans surgeries are being postponed? The world is facing a pandemic and hospital beds need to be kept free. It is unlikely you will hear a trans person say they are angry at COVID-19 patients for taking up space. It is likely however, that you will hear trans people complaining, being angry, being depressed and devastated about their surgeries being postponed, and rightly so. These postponements can be indefinite, with no guarantees about alternate dates. That itself can be a source of psychological hardship and it can be perceived as a societal failure to take trans-identities seriously. This article does not suggest 8 AFAB: assigned female at birth 9 See for example: Human Rights Campaign. "Addressing Anti-Transgender Violence. Exploring Realities, Challenges and Solutions for Policymakers and Community Advocates." 2015, www.assets2.hrc.org/files/assets/resources/HRC-AntiTransgenderViolence-0519.pdf, Accessed: May 13, 2020. that trans surgeries are more important than saving the lives of COVID-19 patients. Instead, it looks at how these medical ethical choices of prioritization have specific impacts on trans people. The assumption that gender-affirming surgeries are much like aesthetic surgeries and thus are not necessary is a misconception. Trans people undergo surgeries because they wish to do so, yes. But their wish is based on a need that is life-altering, and often life-saving (Bränström and Pachankis 2019, Baily et al. 2014, Bauer et al. 2015). Those who classify trans surgeries as aesthetic need to conceive of them as more analogous to reconstructive aesthetic surgeries than to cosmetic procedures that are considered to be based on a wish to move closer to an aesthetic ideal. The intention here is not to weigh different kinds of aesthetic surgeries against each another per se but only in the face of a pandemic that forces prioritization upon hospitals. Like reconstructive surgeries, trans surgeries can be regarded as essential. 19 Skeptics should also know that there are no good alternatives to surgery for many trans people: AFAB folks often wear binders (a chest-flattening garment) so that their chests appear flat. Binders make it difficult to breathe and to move, sweating is greatly enhanced in summer, it is even difficult to put them on and take them off, and back problems from long-term wear might follow. Binders also have more detrimental long-term effects: if worn incorrectly, the chest tissue can deform to such an extent that top surgery with good results becomes impossible. However big the discomfort and risks that come with wearing a binder, many AFAB trans people nevertheless do it because they feel a strong need to present that way. 20 On a broader scale, there is evidence that health outcomes during the pandemic have gotten significantly worse; a United Kingdom study has shown a dramatic spike in mortality, only a quarter of which is linked to COVID-19 (Denaxas et al. 2020). This is likely be due to the pandemic having a negative effect on healthcare and its accessibility in general. Thus it is important to face the fact that measures taken to contain the virus are having a wider impact, especially when important medical procedures get reclassified as non-necessary. 21 Stating that trans surgeries are not necessary falls in line with the historical placement of being trans as a pathology but also with the assumption that being trans is a choice. The assumption that being trans is a choice and therefore one can choose to seek medical transition is often held and made by people who are seemingly liberal towards trans folks. Bettcher warns about the assumption that trans people choose to be trans: A natural question one might ask is why trans people transition. One of the things to observe, however, is that this question is probably already problematic. One might worry that such a question reflects a bias analogous to the question "What causes homosexuality?"-a question that seems to presuppose that heterosexuality is not in need of explanation. [...] If we understand it merely as a conscious self-identification of oneself or as the belief that one is a man or a woman, then it turns out that it cannot be used as a complete explanation of trans gender discontent. (Bettcher 2017, 128) 22 The wrongdoing does not begin with writing off trans surgeries when hospital beds are needed for a pandemic crisis, the wrongdoing begins at a much more basic level, which concerns the foundations of the healthcare system. In Germany, for example, when surgeries that are not considered 'necessary' have been written off, it was immediately obvious that gender-affirming surgeries would fall into this category. They have not been recognized as necessary from the start. 23 If the healthcare systems worldwide were prepared for a pandemic, there would be no need to write off surgeries that might not seem necessary on the surface but that are necessary in order for the respective human being to continue living their life. Mental Health Care 24 As noted, the COVID-19 pandemic does not only affect physical or medicinal trans healthcare, it also affects mental healthcare for trans people. Trans mental healthcare includes not only approved therapists and psychiatrists but also community centers, organizations, and meeting points providing an infrastructure for trans people. Because mental healthcare is harder for trans people to access than for cis people, mutual aid and community spaces serve as a form of mental healthcare that is more essential to trans people than people who have easier access to other forms of mental healthcare. 25 Having a functioning infrastructure is not only important for society as a whole, but especially for marginalized groups who cannot rely on society at large providing them with a safe space to exist. As trans community centers are forced to shut down during the COVID-19 crisis, the infrastructure and the community many trans people rely on are lost. Trans organizations and community services that offer trans consultations can only offer digital consultations for the time being. Thus, there is no place left to go other than public spaces: i.e., spaces where trans people experience discrimination and harassment on a daily basis. Public places that are trans-friendly are extremely important for maintaining psychological well-being for trans people since they can provide a space to feel seen without being stared at, a space free from judgment, a space to explore oneself. 26 A further issue is the added social isolation many marginalized people, including trans people, face in times of this pandemic crisis. Groups that are already affected by marginalization are subject to the restrictions and possible dangers to a greater extent. Social isolation is likely to result from the closing of community centers, bars, cafés, any hang-out spots. Trans people are at a higher risk of having mental health issues like depression or anxiety, and thus ultimately at a higher risk of suicide (Bailey et al. 2014, Bauer et al. 2015). None of this means that trans people are inherently more likely to have depression or anxiety, however. Rather, it is important to acknowledge that the structural and everyday discrimination and violence trans people have to face contribute to and perhaps even constitute the development of depression, anxiety, and suicidal ideation. Isolation during COVID-19 can have a deleterious effect on mental health issues, and, for trans people, that means both a loss of community support and reduced access to trans healthcare, which may compound the impact of lockdowns and exacerbate already existing mental health challenges. 27 There are also fears about the community falling apart. Group meetings and events are an important part of many trans people's everyday lives. Often, these community gatherings provide a space of safety and stability that many trans people do not otherwise have access to (due to having been abandoned by blood family for being trans, due to constant exposure to transphobia, or due to complications in the transitioning process). 28 In addition to organizations and community centers having to close their doors, i.e. important infrastructure for trans people disappearing, a lot of therapists and counsellors have switched to online sessions instead of in-person settings or even have paused therapy altogether. Some counsellors, therapists, and people working for community centers are affected by having to take care of their children at home, which further restricts the time they can dedicate to counselling work. Appointments with psychiatrists and psychologists are not only necessary for mental healthcare for trans people but also necessary to qualify for surgeries or gender marker and name changes in official documents. Transitioning socially and medically goes hand in hand with a lot of discrimination, and thus creates further therapy needs. Already before the COVID-19 crisis it has been difficult to find a competent therapist as a trans person. Many therapists are not familiar with LGBTIQ* issues; getting into the wrong hands as a trans person might well mean that they will not be able to receive HRT, undergo surgeries, or change documents. Being taken seriously as a trans person and not being questioned constantly can result in better mental health. Bailey et al. (2014) have looked at suicide risk in the UK trans population, for example, and found that access to transitioning and surgeries and a supportive environment decrease the risk of suicidal ideation and suicide attempts in trans people. A supportive environment for social transition and timely access to gender reassignment, for those who needed it, emerged as key protective factors (Bailey et al. 2014). 29 Some mental healthcare is still available via online services. However, this crisis also shows how access to the digital community is different at different intersections of identities. Younger trans folks who are digitally skilled and economically stable enough to afford a smartphone or another device with internet access might experience less of a sense of community loss than older trans folks who are not digitally skilled and poor trans people who cannot afford a device to access the internet. There are also trans people who do not have safe private living spaces; for example, trans people who live with their family of origin which is not supportive. For them, having to do virtual therapy sessions in a shared home environment is just not safe or realistic. Access to free wi-fi has also been dramatically reduced with the closure of cafés, libraries, and other public places. There are many trans people who do not have access to digital services due to economic instability, homelessness, or other reasons. These disparities become all the more obvious in the COVID-19 pandemic, where the possibility to rely on digital services provides us with a replacement for the physical infrastructures that have been lost. Conclusion 30 The COVID-19 pandemic highlights inequalities at different levels and intersections. The pandemic has placed an additional burden on trans healthcare and thus helped shed light on how trans people are affected by the pandemic. This is vital to understanding social inequalities and to understanding that social inequalities tend to get even more emphasized in times of crisis. 31 A lot of trans healthcare services have discontinued during this crisis. As discussed, this raises ethical questions around prioritization of and discrimination against trans people in the healthcare system. This paper has explored how the re-classification of trans surgeries and procedures as non-necessary during the pandemic is based on an understanding of trans healthcare as not essential. 32 Removing barriers in healthcare for trans people before the pandemic would have led to trans people being less affected by the COVID-19 pandemic on a physical and mental level. In addition, removing barriers in healthcare for trans people would possibly have allowed the healthcare system to respond to the effects of the pandemic on trans healthcare in a more reasonable and flexible way. Works Cited Appenroth, Max Nicolai and do Mar Castro Varela, Maria. "Einleitung. Trans & Care: Das Recht auf eine gute Gesundheitsversorgung, Pflege und Sorgearbeit." [„Introduction. Trans & Care: The Right to proper Healthcare, Care, and Care Work."] Trans & Care: Trans Personen zwischen Selbstsorge, Fürsorge und Versorgung, [Trans & Care: Trans People between Self-Care, Care, and Supply.] edited by Max Nicolai Appenroth and Maria do Mar Castro Varela. Transcript Verlag, 2019, pp. 19-32. Bailey, Louis and Ellis, Sonja & Mcneil, Jay. "Suicide risk in the UK Trans population and the role of gender transition in decreasing suicidal ideation and suicide attempt." Mental Health Review Journal, vol. 19, no.4, 2014, pp. 209-220. Bauer, Greta R. et al. "Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada." BMC Public Health, vol. 15, no. 525, 2015, pp. 1-15. Bauer, Greta R., et al. " 'I Don't Think This Is Theoretical; This Is Our Lives': How Erasure Impacts Health Care for Transgender People." Janac-Journal of the Association of Nurses in Aids Care, vol. 20, no.5, 2009, pp. 348-361. Bauer, Greta R., et al. „Reported Emergency Department Avoidance, use, and Experiences of Transgender Persons in Ontario, Canada: Results from a Respondent-Driven Sampling Survey." Annals of Emergency Medicine, vol. 63, no. 6, 2014, pp. 713-720. Beemyn, Genny, and Rankin, Susan. The lives of transgender people. New York, NY: Columbia University Press, 2011. Bettcher, Tallia Mae. "Appearance, Reality, and Gender Deception: Reflections on Transphobic Violence and the Politics of Pretence." Violence, Victims, and Justifications, edited by Felix Ó Murchadha, New York: Peter Lang, 2006, pp. 175200. Bettcher, Tallia Mae. "Evil Deceivers and Make-Believers: On Transphobic Violence and the Politics of Illusion." Hypatia, vol. 22, no.3, 2007, pp. 43–65. Bettcher, Tallia Mae (2017) "Trans 101." The Philosophy of Sex. Contemporary Readings. Seventh Edition, edited by Raja Halwani et al., Rowman & Littlefield, 2017, pp. 119138 . Bradford, Judith, et al. "Experiences of TransgenderRelated Discrimination and Implications for Health: Results From the Virginia Transgender Health Initiative Study." American Journal of Public Health, vol. 103, no. 10, 2013, pp. 18201829. Bränström, Richard and Pachankis, John E. "Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study." European Journal of Public Health, vol. 29, no. 4, 2019. Banerjee, Amitava et al. "Estimating excess 1year mortality from COVID-19 according to underlying conditions and age in England: a rapid analysis using NHS health records in 3.8 million adults." MedRxiv. The Preprint Server for Health Science, 2020. Cicero, Ethan C. et al. "Health Care Experiences of Transgender Adults: An Integrated Mixed Research Literature Review." Advances in Nursing Science, vol. 42, no. 2, 2019, pp. 123138. Deutsche Gesellschaft fuer Sexualforschung (DGfS). "Geschlechtsinkongruenz, Geschlechtsdysphorie und Trans-Gesundheit: S3-Leitlinie zur Diagnostik, Beratung und Behandlung". [„Gender Incongruence, Gender Dysphoria, and Trans Health: S3 Guidelines for Diagnosis, Consulting, and Treatment."], 2019, www.awmf.org/uploads/tx_szleitlinien/138-001l_S3_Geschlechtsdysphorie-DiagnostikBeratung-Behandlung_2019-02.pdf. Accessed: May 5, 2020. Grant, Jaime M. et al. "Injustice at every turn: a report of the National Transgender Discrimination Survey." 2011, www.transequality.org/sites/default/files/docs/resources/NTDS_Report.pdf. Accessed: May 5, 2020. Kattari, Shanna K. et al. "Barriers to health faced by transgender and non-binary black and minority ethnic people. A Race Equality Foundation Briefing Paper." 2016, www.raceequalityfoundation.org.uk/wp-content/uploads/2018/02/Better-Health-41Trans-NB-final.pdf, Accessed: June 09, 2020. Kattari, Shanna K. et al. "Racial and ethnic differences in experiences of discrimination in accessing health services among transgender people in the United States." International Journal of Transgenderism, vol. 16, no. 2, 2015, pp. 68-79. Loos, Franziska K. et al. "Subjective indicators of treatment success and experiences of discrimination in interdisciplinary trans* healthcare. Qualitative results from an online survey." Zeitschrift für Sexualforschung, vol. 29, no.3, 2016, pp. 205223. Marshall, Ellen, et al. "Non-suicidal self-injury and suicidality in trans people: A systematic review of the literature." International Review of Psychiatry, vol. 28, no.1, 2016., pp. 5869. Murad Mohammed H., et al. "Hormonal therapy and sex reassignment: a systematic review and metaanalysis of quality of life and psychosocial outcomes." Clinical Endocrinology, vol. 72, 2010, pp.214 – 231. Salerno, John P. et al. "Health Care Experiences of Black Transgender Women and Men Who Have Sex With Men: A Qualitative Study." Journal of the Association of Nurses in AIDS Care, 2019. Sauer, Arnt and Nieder, Timo. "We care. Überlegungen zu einer bedarfsgerechten, transitionsunterstützenden Gesundheitsversorgung." [„We care. Reflections on a needsbased, transition-supporting health care.".] Trans & Care: Trans Personen zwischen Selbstsorge, Fürsorge und Versorgung [Trans & Care: Trans People between Self-Care, Care, and Supply.], edited by Max Nicolai Appenroth and Maria do Mar Castro Varela. Transcript Verlag, 2019, pp. 75-101. Serano, Julia. „Psychology, Sexualization and Trans-Invalidations." Keynote lecture presented at the 8th Annual Philadelphia Trans-Health Conference. June 12, 2009, www.juliaserano.com/av/Serano-TransInvalidations.pdf. Serano, Julia. Excluded. Making Feminist and Queer Movements More Inclusive. Berkeley: Seal Press, 2013. Smedley, Brian, et al. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: The National Academies Press, 2003. Sperber, Jodi, et al. "Access to health care for transgendered persons: Results of a needs assessment in Boston." International Journal of Transgenderism, vol. 8, no. 2-3, 2005, pp. 75-91. Stoljar, Natalie. "Discrimination and Intersectionality." The Routledge Handbook of the Ethics of Discrimination, edited by Kasper Lippert-Rasmussen, New York: Routledge, 2018, pp. 287–298. Turner, Lewis et al. "Transphobic Hate Crime in the European Union. A Research Project sponsored by ILGA-Europe and Press for Change.", 2009, www.ilgaeurope.org/sites/default/files/transphobic_hate_crime_in_the_european_union_0.pdf. Accessed: April 19, 2020. World Health Organization. ICD-10: international statistical classification of diseases and related health problems, 10th revision, 2nd ed., 2004. World Health Organization. International classification of diseases for mortality and morbidity statistics, 11th Revision, 2018, www.icd.who.int/browse11/l-m/en. Accessed April 19,2020. World Professional Association for Transgender Health (WPATH). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 7th Version., 2011, Minneapolis: WPATH. Xavier, Jessica M. et al. "A needs assessment of transgendered People of Color living in Washington, DC." International Journal of Transgenderism, vol. 8, no. 2-3, 2005, pp. 3147.