LONDON - Anya, a Canadian transgender woman, planned to undergo surgery this month to make her face more feminine and to address the discomfort she has felt with her body since male puberty.
But the procedure was postponed indefinitely in mid-March as non-emergency surgeries were cancelled globally to combat the new coronavirus, leaving Anya battling anxiety and distress as she waits for the C$86,000 (P3.10 million) life-changing operation.
"I've been been waiting my whole life for this procedure... waiting a little bit longer is not the end of the world," said the 26-year-old, who hopes the surgery will stop her being harassed in public for being trans.
"What scares me is... people saying it's going to be years before we're going to have a vaccine and things are never going back to normal," Anya, who declined to publish her full name, told the Thomson Reuters Foundation.
"My fear is never getting my care."
The COVID-19 pandemic has left hundreds of trans people in limbo as they wait for surgery, which is effective in reducing depression and suicidal feelings that often occur when people do not identify with their biological sex.
Not all trans people have gender reassignment surgery, which can include the removal of breasts, creation of a vagina and voice feminization at public and private hospitals from the United States and Spain to Thailand, India, and Australia.
But for many, like Anya, surgery is essential to alleviate their gender dysphoria, or distress caused by the conflict between their body and gender identity.
In the United States, where Anya planned to have her surgery, more than a dozen states have halted elective procedures, like hip replacements, to expand capacity for intensive care to address the coronavirus crisis.
"We consider (gender reassignment surgeries) as elective," said a spokeswoman for the American College of Surgeons, an association which has advised US surgeons to reschedule elective surgeries to deal with an influx of COVID-19 patients.
While billions globally are under stress amid coronavirus lockdowns, trans people are particularly vulnerable because they suffer high rates of mental illness, exacerbated by family rejection, discrimination and lack of access to healthcare.
Almost one in two trans adults have seriously thought about suicide in the past year - a rate 12 times higher than the general US population, according to the National Center for Transgender Equality advocacy group.
Jacob, a 20-year-old support worker at an Australian clinic which cares for trans people, was due to have a double mastectomy in a public hospital in May after a 2-year wait.
Australia indefinitely suspended all non-urgent elective surgery on March 25, only allowing treatment to go ahead for patients who would otherwise deteriorate into an emergency situation within 30 days.
"I understand why it has to be (postponed)" said Jacob, who declined to publish his full name. "But it kind of gives this feeling of hopelessness. Just not knowing (when the surgery will take place) is massively anxiety-inducing."
Gender reassignment surgery can significantly improve trans people's mental health and reduce suicidal behavior, according to a study by Sweden's Karolinska Institutet and Yale School of Public Health.
The likelihood of being treated for a mood or anxiety disorder fell by 8 percent for each year since the last gender-afﬁrming surgery for up to 10 years, it found.
With long waiting times and high prices in the West, India is a popular destination for trans patients but the government has advised hospitals to postpone all non-essential surgeries.
Richie Gupta, a surgeon in a private hospital in New Delhi, which normally performs a dozen gender reassignment procedures a month, said one of his patients has been left stranded after a lockdown was announced on March 24.
"Every day she asks me when I'll be able to do her surgery, but my hands are tied," said Gupta, adding that the woman from the southern city of Bengaluru was paying for food and accommodation while trapped in the capital.
"She is quite upset... she had come here for a purpose and taken a loan for the procedure and now she will be going back home without surgery once the lockdown is lifted," he said.
Uncertainties around surgery can aggravate pre-existing mental stress associated with gender dysphoria, he said.
"Endless waiting... can cause a patient to feel more anxious and depressed," said Gupta, one of India's leading gender reassignment surgeons.
"They look forward to (surgery), they consider it as their rebirth. So it's a very sad situation right now."
After the lockdown, doctors still may not be able to perform surgeries for months as many hospitals - including his own, Fortis Hospital in Shalimar Bagh - cannot test for coronavirus, Gupta said.
The coronavirus crisis has not disrupted all trans treatments - and it may even bring unexpected benefits.
Some doctors have found a new way of working - conducting appointments by video and phone, including teaching young trans men to give themselves testerone injections to create masculine body characteristics like facial hair. "We have a very, very tight network throughout the US of electronic prescribing, of telephone prescribing, and the vast majority of pharmacies are open," said Morissa Ladinsky, a doctor who works with young trans people.
Almost 80 US gender clinics are undertaking a joint study to see if working with young trans patients virtually because of COVID-19 proves better for their mental health than traditional appointments, Ladinsky said from the southern state of Alabama.
Some patients already appear more comfortable being assessed for gender dysphoria and receiving mental health support online, rather than in-person, she said.
"When we see youth in their homes, with pets on their lap, as they're talking about the really tough stuff ... they feel freer," she said.
"We see a side of our youth that we don't always get to see. They're with us, but they're in their safe space."