Being an outsider: transgender and non-binary experiences within online endometriosis communities

Abstract

Endometriosis is a chronic and painful disease that has a detrimental effect on people’s quality of life. Endometriosis is known as a lonely disease. Assigned female at birth transgender and non-binary people with endometriosis’ narratives are rare in literature. Cisgender women have reported experiencing support from online endometriosis community platforms. The aim of our international study was to explore transgender and non-binary people with endometriosis experience of support and integration from online endometriosis communities. With the use of Hermeneutic Analysis, we developed the following three themes to describe 11 transgender and non-binary people with endometriosis experience of support and integration from online endometriosis communities: (1) feeling isolated due to a lack of inclusive endometriosis support groups, (2) exclusion because of gendered language in endometriosis support groups, and (3) experiences of transphobic hate from endometriosis communities. We used Phenomenology of Embodiment as our theoretical point of departure as this theory interlinks the relationship we have with our bodies and the social world. Findings revealed that participants were isolated and left with a lack of support from online endometriosis communities. In addition, they were often left to deal with difficult feelings as a result of the transphobic hate they experienced from endometriosis communities. We recommend that endometriosis support platforms and endometriosis organisations that have online support platforms utilise both gender-inclusive language and gender diversity inclusion practices to support inclusion in these online spaces for all who have endometriosis.

Introduction

Without even a voice to live, how can we then have a voice in other spaces, especially ones that are so gendered. So, I think since we are already having struggles with our voice just to begin to live with life, it would really have to improve before we could be like, ‘Oh we can live a life and with endo and be heard’.

We begin our article with the voice from one of our participants, Jru, a 29-year-old non-binary individual from the United States. In this quote, Jru had answered a question regarding inclusion from endometriosis communities. In Jru’s answer, they reflected on the oppression of LGBT voices in society and then amalgamated this to the absence of transgender and non-binary people with endometriosis voices being heard. Endometriosis is a chronic, inflammatory, and painful disease in which endometrial-like tissue grows outside of the uterus, which can result in a detrimental impact on people’s quality of life (Zondervan et al., 2020). The exact cause of endometriosis is unknown except that it is mediated by hormones and it is linked with menstruation (National Institute for Health and Care Excellence [NICE], 2017). It primarily affects people in their reproductive years, although it can be a lifelong condition (NICE, 2017). Endometriosis can have a significant impact on a person’s physical, psychological, sexual and social wellbeing with people struggling with symptoms of chronic pelvic pain, painful menstruation, problems with their bowel and their bladder, pain with sex, and problems with their fertility (NICE, 2017). The NICE (2017) guidelines refer to endometriosis affecting women and so does much of the discourse on endometriosis centre on cisgender (where one’s gender identity aligns with their gender assigned at birth [Treat it Queer, 2025]) women with endometriosis (Jones, 2020). There are limited studies on AFAB (assigned female at birth) transgender and non-binary people with endometriosis (Batchelor & Vasquez, 2023; Ferrando, 2022; Jones, 2020; Okita et al., 2021; Shim et al., 2020; Vallée et al., 2023). Transgender people’s narratives of their experience of endometriosis are absent from literature (Chadha, 2020).

Transgender people’s gender differs from the gender they were assigned at birth and they can identify within the binary of gender, male or female, or they can be non-binary (Treat it Queer, 2025). Non-binary refers to people who do not identify with the social binaries of gender (Treat it Queer, 2025). Transgender and non-binary people are considered a vulnerable community and are at a greater risk of violence, discrimination and marginalisation (United Nations Human Rights [UNHR], 2024). Transgender and non-binary people have shared experiences of discrimination when they seek health care (Grant et al., 2010; UNHR, 2024). Cisgender women have shared problems in their health care for endometriosis where they felt not heard and without support from health care providers (HCPs) (Girard et al., 2023; Márki et al., 2022). Transgender and non-binary people with endometriosis have shared experiences in which they had additional barriers in receiving health care for their endometriosis with experiences of medical gaslighting, the use of gendered language, being misgendered by HCPs and experiences of discrimination by HCPs (Eder & Roomaney, 2023). Giacomozzi and colleagues (2024) have highlighted that transgender and non-binary people have different health care needs for their endometriosis and they recommended gender-affirming treatment (the practice where transgender and non-binary people receive care that recognises, acknowledges, includes, and supports their gender identity [Treat it Queer, 2025]). More research is needed in the treatment of endometriosis and those that use testosterone for gender affirming purposes as current research shows that testosterone may be gender affirming and can help with some endometriosis symptoms as it can cause amenorrhea (Giacomozzi et al., 2024). Menstruation for transgender people with endometriosis can trigger gender dysphoria (Eder & Roomaney, 2024). Although testosterone may be gender affirming, it does not resolve all of the symptoms of endometriosis and may result in a hyper-estrogenic state which may exacerbate endometriosis (Giacomozzi et al., 2024). Transgender and non-binary people with endometriosis have reported experiences of rejection and isolation from their family, friends, significant partners, work colleagues and other supports because of their endometriosis and their gender identity (Eder & Roomaney, 2025). Transgender and non-binary people with endometriosis having different health care needs for their endometriosis (Giacomozzi et al., 2024), experiences of isolation and rejection (Eder & Roomaney, 2025) and experiences of discrimination and isolative practices from HCPs (Eder & Roomaney, 2023) for an already known isolative disease (Moradi et al., 2014; Peterson et al., 2023), may leave them needing to access other support resources.

Endometriosis online support groups are considered a helpful aid in supporting those with endometriosis (Adler et al., 2024; Goel et al., 2023). Endometriosis online peer interactions can be helpful in that these interactions may support people with managing feelings of isolation and despair, validation of their experience, reassurance, shared experience and support in the management of living with endometriosis (Lindgren & Richardson, 2023). Holowka (2022) has highlighted that online endometriosis support spaces are not always supportive and they can feel unsafe for transgender and non-binary people when gendered language regarding endometriosis is used. Our study explores the missing voices of transgender and non-binary people with endometriosis experience of integration and support from online endometriosis communities. In the next section, we discuss Phenomenology of Embodiment as our theoretical point of departure in relation to the study.

Merleau-Ponty and Landes (2014) argued that there is reciprocity between the world and the body, where both the body and the world inform each other. We applied this theory as it can aid in our description of the impact that endometriosis has with the body, self and world, but also the impact these relationships have with one’s gender identity, and the combination of living with endometriosis and being transgender and non-binary. The body and the world are intertwined with one another, and therefore we can have an impact on the world, and the world impacts us (Merleau-Ponty & Landes, 2014). Chronic pain, which is a primary symptom in endometriosis (NICE, 2017), can fragment the relationship between our bodies and the world as the body becomes the centre of our experience (Bullington, 2009; Leder, 1990). Living with an illness can sever our sense of meaning in our day-to-day lives (Svenaeus, 2014). Svenaeus (2014) referred to this sever from illness as a sense of unhomelikeness in our relationship with ourselves, the body and our being-in-the-world. There may be a layering of the experience of unhomelikeness for transgender and non-binary people with endometriosis as they need to manage a sense of unhomelikeness of living with endometriosis, experiences of unhomelikeness of endometriosis triggering gender dysphoria, and experiences of rejection because of their gender identity and their endometriosis (Eder & Roomaney, 2024; Eder & Roomaney, 2025). A more homelike state with living with an illness may be possible through support (Svenaeus, 2014). The reciprocal relationship between the body and the world may be useful to consider in relation to transgender and non-binary people with endometriosis as they need to manage the devastating effect this disease has on their body, while they mitigate support and a relationship with the world.

Our aim in this article was to explore transgender and non-binary people with endometriosis experience of integration and support from online endometriosis communities.

Methods

Positionality

The first author is a cisgender woman with endometriosis who wrote her PhD on the lived experience of transgender and non-binary people with endometriosis after seeing a social media post where a transgender person shared his feelings of exclusion in living with endometriosis. The second author is a cisgender woman and is the first author’s PhD supervisor.

Participants

We recruited participants for this study with the use of purposeful and snowball sampling. We advertised for participants on endometriosis support groups and transgender endometriosis support groups on the social media platform, Facebook. Our advert specified the inclusion criteria. Participants needed to be transgender and/or non-binary, have been diagnosed or had suspected endometriosis, be able to speak English and be 18 years or older. We had no geographical restrictions for the study. Participants were not compensated; however, they were gifted a small gratuity of a $10 Amazon gift card for their time in taking part in the study.

Eleven participants volunteered for the study and they resided internationally, namely, Canada, Ireland, the United States, Australia, New Zealand, the United Kingdom, and Norway. All participants were AFAB. One participant was transmasculine, two were transmasculine and non-binary, and eight participants were non-binary. All but one participant had a diagnosis of endometriosis confirmed from a laparoscopic surgery. Participants reported that endometriosis had a devastating impact on their quality of life with negative impacts on their physical wellbeing, gender identity, social relationships, sexual wellbeing, psychological wellbeing, their work, their finances, hobbies, and their lifestyles as a whole. Only three participants reported that their gender identity was included as part of their endometriosis treatment. The youngest participant was 21 years old, the eldest was 31 years old, and the average age of participants was 26 years. Participants described their population group demographics as the following: one participant was Norwegian, one participant was British, one participant was mixed race and Asian, six participants were white, another participant was Caucasian and Jewish and one person shared they were Ashkenazi Jewish. Four participants were migrants from the United States, the United Kingdom, and Africa and had migrated to New Zealand, the United Kingdom, Australia, and Canada.

Instruments

We developed an interview guide with open-ended questions for a broader study. We developed the guide through reading and reflection on transgender endometriosis blogs and we created broad open-ended questions with the aim that participants could share their lived experience. We then asked follow up questions based on participants’ narratives. The questions focussed on their experience of being transgender and/or non-binary and living with endometriosis, health care, psychosocial support, and their integration and support from endometriosis communities. In this article, we have focussed on participants’ experience with their integration with online endometriosis communities. Participants completed a digital diary for 3 months in which they reflected on their everyday experience of endometriosis.

Procedure

We conducted three online semi-structured interviews with each participant. Participants could choose to use Skype or Zoom and if they wanted to keep the camera on. Interviews were approximately 60 min each. Interviews were conducted in English. Participants consented to the recording of the interviews.

Ethical considerations

This study has been approved through the Health Research and Ethics Committee at Stellenbosch University with reference number: S21/07/118. All participants signed consent forms which outlined our contact details, ethics approval, the purpose of the study, remuneration, what participation would involve, protection of their anonymity, an offer of counselling if they felt they needed this due to the sensitive nature of the study, and consent to the publication of the findings. We have used pseudonyms to protect participants’ identities.

Data analysis

For our data analysis, we followed a Hermeneutic analytic approach with the implementation of Patterson and Williams (2002) seven-step method. After conducting the interviews and collecting the diaries, we first transcribed the interviews and then we read both the transcripts of the interviews and the diaries. In the second step, we numbered the lines of the transcribed interviews and the diaries, so that we could create a referencing system. We transferred the referenced data onto Atlas ti. Third, we read and reread the data, and we kept a journal in which we captured our reflections of the data. Fourth, we highlighted sections of data and coded these in Atlas ti, thereby creating meaning units. In the fifth step, we developed themes by reflecting on the meaning units. Step six involved an examination of the interconnections in reference to the themes. The last step involved writing up the findings in which we referred to the interconnections between the themes, reflections between the authors, and through the reflection of the theoretical point of departure of Phenomenology of Embodiment. We referred to the Hermeneutic circle in this process as we reflected and moved between the data, our reflections on the data, and our analysis on our reflections and the application of the theory.

Findings

From the data analysis described above, we discuss three themes in relation to transgender and non-binary people’s experience of the support and integration they experienced from online endometriosis communities. The three themes we discuss are the following: (1) feeling isolated due to a lack of inclusive endometriosis support groups, (2) exclusion because of gendered language in endometriosis support groups, and (3) experiences of transphobic hate from endometriosis communities.

Feeling isolated due to a lack of inclusive endometriosis support groups

Participants shared how they found very few gender inclusive endometriosis support groups. They were able to find separate transgender and non-binary support groups and endometriosis support groups; however, they found many of the endometriosis support groups were not gender inclusive. Daniel, a 21-year-old transmasculine non-binary individual from Norway, shared his experience of very limited information or support groups for transgender people with endometriosis online:

Yes I found nothing . . . when I surfed last year, I found nothing, absolutely nothing. . . It’s scary because it makes me feel alone.

Daniel was left feeling scared and alone when he was looking for support for his endometriosis. This is significant when we take into account that transgender and non-binary people with endometriosis feel unsupported in their health care for endometriosis and their gender identity (Eder & Roomaney, 2023) and are isolated (Eder & Roomaney, 2025).

Many participants reported that they felt excluded from endometriosis communities because of their gender identity and the lack of gender inclusivity on these social platforms. Onyx, a 21-year-old non-binary individual from New Zealand, shared how they felt when they tried to engage with endometriosis communities:

I think quite isolated again, because I think there its even though endometriosis feels pretty invisible anyway, you then kind of feel invisible to your own community too, who are supposed to just understand and relate to you, which they still do but it’s difficult when you are not included in that way [gender identity].

We can perceive from what Onyx shared that they experienced a layering of isolation when they had to manage a disease that they experienced as invisible and then they were left unsupported by online endometriosis communities in relation to their gender identity.

A few participants shared that they found it meaningful when they located gender inclusive endometriosis support groups and the rare transgender and non-binary endometriosis support groups on social media, such as Endo Knows No Gend-O, Quendo, Endo Siblings Support and Endo Queer on Facebook as they found an online space where they could connect and share their experiences. Some of the participants reported that they had their own social media pages where they created awareness on endometriosis for transgender and non-binary individuals. Participants created these pages because they wanted to help other transgender and non-binary people with endometriosis to not feel as alone as they had felt. Participants with their own social media endometriosis pages reported receiving hateful comments on their platform from transphobic people with endometriosis, which resulted in distress and them needing to take a break from social media. Sage, a 21-year-old transmasculine individual from England, who had created his own page shared feeling triggered when he received hate posts, ‘I was really sad and frustrated and with things like that I get really heated because there is so much transphobia in the world right now’. It is important to highlight the impact transphobia can have when we consider that transgender and non-binary people have minority stress and have the added layer of struggling with the isolative disease of endometriosis. In addition, Sage reported feeling stressed after the health system reported him to Immigration after he requested to change his title and he feared being deported. We can observe a culmination in rejecting and isolative experiences when Sage reached out for support. We share more on Sage’s experiences with transphobic hate under theme three. From these experiences, we can conclude that participants had minimal options available in relation to support from endometriosis communities.

Exclusion because of gendered language in endometriosis support groups

Participants shared that they found many of the endometriosis online support groups were not supportive when they were not gender inclusive and they used gendered language, such as: ‘woman’s disease’, ‘one in ten women’, ‘you got this ladies!’, ‘endo sisters’. The use of gendered language left participants feeling that they did not belong. Jo, a 25-year-old non-binary individual from Ireland, shared how gendered language regarding endometriosis left them feeling excluded from endometriosis communities. Jo shared,

The language [gendered language] that was being used and I just kind of felt like, I just didn’t belong. That was the feeling I had, I felt isolated and just that I didn’t fit in properly.

Sawyer, a 31-year-old non-binary individual from Australia, shared how gendered language on social media platforms affected them:

Uncomfortable and yeh just like anxious and triggered and stuff by it because it’s like you have to read through all of it, like you still want to read all the information, you still want to learn all the stuff and talk to people but there’s a lot of gendering stuff that is hard to sift through and constantly bombard yourself with.

From Sawyer’s quote, we can recognise that Sawyer wanted to utilise these platforms to receive support, but in the process was triggered with gendered language that left them feeling anxious. Participants did not share much content on these groups or how the groups’ content was helpful or unhelpful. From Sawyer’s quote, we can interpret that participants were triggered by gendered language and therefore were not able to fully engage in the content.

Participants reported that some endometriosis online platforms were trying to use more inclusive language. Jo shared,

It’s been nice when I go online and I see people like, you know Endogram and stuff, and she is putting up posts you know that it is not a female disease, and she uses such inclusive language and that’s just comforting.

We can see from Jo’s quote that they experienced support and they were comforted by an endometriosis support platform using inclusive language.

Experiences of transphobic hate from endometriosis communities

Participants reported that they felt excluded when they shared their gender identity in endometriosis communities and that they experienced hate from members’ comments and down liking of their comments when they opened up online in relation to their gender identity. Crow, a 31-year-old non-binary individual from Canada, shared their experience of disclosing their gender identity and the hate they experienced:

You get down voted to hell and you get hate brigaded, like you get brigaded on Reddit and you will have people go through your post history and just down vote everything they possibly can in droves.

Crow’s quote indicates deliberate, negative behaviour that can be considered as calculated and hateful towards them because of their gender identity. Participants shared how they did not feel safe to come out regarding their gender identity online as they feared discrimination. Jru shared an experience in which they came out to an endometriosis community member online and the person left the conversation when Jru shared their gender identity. Jru described this encounter as ‘a deal breaker for people’. Jru shared how this impacted them and their anxiety about sharing their gender identity with the endometriosis community in the future:

So I would just hope that if a person like me came out and said I have endo, hopefully we’re not quote and unquote shot down for it automatically because we’re not the majority and what is assumed to be the only way. Otherwise we’ll never be able to be heard.

A number of participants spoke about their experience with endometriosis being erased because of their gender identity being rejected, which resulted in them feeling isolated and attacked. Participants recalled experiences of transphobia on social media platforms. Sawyer shared how their experience of being transgender and having endometriosis was discounted online with the comment, ‘Oh well I don’t believe in this! [referring to being transgender]’. Sage shared an experience he had when he wrote a post about transgender men’s experience with endometriosis and how he managed his dysphoria:

A cisgender woman with endo commented, ‘Well trans people can’t have infertility from endo, trans doesn’t count’. And that was really hurtful because firstly, trans people can still get pregnant and they were incredibly misinformed. So although I haven’t tried to get pregnant, I could still have infertility problems, and probably trans and non-binary people suffer with similar issues. Secondly just saying that trans people with endo don’t count because they don’t have infertility problems is frustrating.

In the quotation, it appears as though Sage’s experience was totally negated by a group member due to his gender identity. Sage shared how the problem escalated later:

Two other people who followed them came into my comments and commented that I was disgusting, that I was not worthy of being a man, that I’m spreading misinformation about trans people having endo. Which was horrible . . . and traumatic.

We can see how Sage’s experience of hate comments and transphobia may have left him feeling traumatised, after he had opened up about his experience.

Crow shared their experience of feeling like they did not exist according to endometriosis communities:

We don’t exist. That’s basically it, we don’t exist and then we are like, We exist! It’s like, no you fucking don’t. Shut up shut up, you are invalidating my woman hood by existing and having the same fucking disease as me. Get back in the box. We don’t want you here. So, it’s either worse cause like, you had to, but no I need help!

From Crow’s quote, we can perceive how Crow experienced and witnessed encounters online, in which they felt rejected, hated, invalidated and that their experience was erased because of their gender identity, when they really needed help and support. Participants shared that they did not want to take anything away from cisgender women but they wanted to be included. Sawyer shared, ‘It’s a disease that affects people. It doesn’t take away anything from saying that’.

Participants expressed a feeling of gratitude when they had rare experiences of support from online endometriosis communities. These experiences of support included encounters where people online would support them when they experienced hate online, by challenging the hate comments or checking in on them afterwards, offering them support. Sage shared how receiving supportive comments after he had experienced hateful transphobic comments online helped him to feel a little bit safer, ‘I had cis allies who were just showing their solidarity and expressing how sorry they are that people are transphobic. . . It makes you a little bit safer’. Some participants reported that some moderators of these platforms tried to remove transphobic posts and had rules regarding inclusivity when you join the group. Robin, a 26-year-old non-binary individual from Australia shared their experience of a community page they were on that removed transphobic posts, ‘I’ve seen like anti transmen and straight away the moderators will take it down and everyone will comment ‘It’s not okay’’. Robin experienced the post as ‘upsetting’ but ‘reassuring that it’s not everyone’. While these attempts at inclusion were appreciated, on the whole participants felt unsupported, invisible and hated in mainstream endometriosis communities.

Discussion

From the findings, we observed that there is a lack of support from online endometriosis communities for transgender and non-binary people with endometriosis. We found that online endometriosis social media platforms excluded transgender and non-binary people with endometriosis by using gendered language. We further identified from participants’ experiences that online endometriosis communities exclude transgender and non-binary people with hate and discriminatory postings and behaviour. Therefore, not only is there limited support for transgender and non-binary people with endometriosis from online endometriosis communities, but in addition online endometriosis communities can be harmful when they inflict hate to transgender and non-binary people with endometriosis, who are already facing challenges on several fronts with experiences of isolation and loneliness due to their gender identity (Anderssen et al., 2020; Hajek et al., 2023; Puckett et al., 2023).

Under the first theme, feeling isolated due to a lack of inclusive endometriosis support groups, we discussed findings of how participants experienced isolation as a result of a lack of inclusive endometriosis online support groups. There are a number of studies on cisgender women that report that endometriosis online support platforms can be helpful and supportive (Adler et al., 2024; Goel et al., 2023). Transgender people experience marginalisation, high levels of isolation (Anderssen et al., 2020; Hajek et al., 2023) and are stigmatised by family and their peers, leaving them vulnerable and with negative effects on their mental health (Abreu et al., 2019). There seems to be a layering of isolation for transgender and non-binary people with endometriosis as they first experience exclusion from the community. Second, transgender and non-binary people with endometriosis may have a layer of isolation as endometriosis is an isolating disease (Cole et al., 2021). Third, transgender and non-binary people with endometriosis may have an additional layer of isolation as they are excluded from endometriosis communities in which they have something in common with.

Under the second theme, exclusion because of gendered language in endometriosis support groups, we shared participants’ experiences of how gendered language within endometriosis online social media platforms affected them, which made them feel that they did not belong to the group and left them with difficult feelings to manage. Gendered language can invalidate a person’s gender identity as it contributes to gender stereotypes, biases and that gender is binary (Bigler & Leaper, 2015). Using gendered language can result in harm to transgender and non-binary people as it applies non-recognition, exclusion and a lack of understanding of gender diverse people living in society (Dev et al., 2021). The gendered language that is used to describe endometriosis as a cisgender women’s disease erases transgender and non-binary people with endometriosis (Jones, 2020). The use of gendered language on endometriosis support platforms results in transgender and non-binary people with endometriosis excluded.

In the third theme, experiences of transphobic hate from endometriosis communities, we discussed the impact that experiencing hate and discrimination on these endometriosis online support groups had and how transgender and non-binary people wanted to feel included so that they could gain support from endometriosis communities. Online hate of the LGBT community can result in emotional distress, problems with sleep, depression, stress, and feelings of fear and panic (Nyman & Provozin, 2019). One of the most common feelings that LGBT people feel when they experience hate online is sadness and depression which later evolves into shame and self-blame as they blame their identity rather than the perpetrator (Keighley, 2022). LGBT people’s experience of hate online results in isolation from people both online and offline (Keighley, 2022). Participants reported feeling fear, excluded, invalidated, hated, traumatised, isolated, frustrated, and erased.

The relationship we have with the world and our bodies are reciprocal in nature, with both informing and impacting each other (Merleau-Ponty & Landes, 2014). Living with a chronic illness can result in an alienation and unhomelikeness from our bodies (Svenaeus, 2015). We can observe from our participants’ experiences that not only did they experience alienation from their bodies as a result of living with a chronic disease, but experiences of rejection and isolation from endometriosis communities. These experiences of rejection and isolation have a negative impact on the relationship they have with the world and have left them unsupported towards a more homelike sense in living with endometriosis. In addition to this experience of rejection and isolation from endometriosis communities, it is important to reflect on the relationship that our participants have with the world, when we consider the broader context that often transgender and non-binary people are already isolated (Hajek et al., 2023). In our study participants reported rare accounts of support in which people in endometriosis communities would support them when they experienced hate online or where people showed genuine care and inclusion. From participants’ experiences, they are rejected and isolated from the world, with regard to endometriosis communities.

There were limitations to this study. First, participants were recruited internationally, which may limit country specific socio-political contextual data. Second, this study was conducted online, which may have excluded people who do not have access to technology. Although there are studies on cisgender women with endometriosis experience of online endometriosis platforms, it may be helpful to research their perception of experiences with transgender and non-binary people online so that difficulties they experience may be identified, as their voices are missing from this research. This study was limited in its discussion on intersectionality to disability and gender. Exploration of other intersections may be beneficial in future research.

Conclusion

Our participants shared their experiences of isolation, a lack of support and integration from online endometriosis communities. Our participants experienced a lack of inclusive support groups. Many participants reported that online endometriosis platforms use gendered language which left them excluded. Participants reported experiences of hate and discrimination online which resulted in them being isolated. We recommend that endometriosis online support groups implement gender inclusivity so that transgender and non-binary people can receive the much-needed support of living with endometriosis.