Hugo dreamt of studying at Queensland's Conservatorium of Music but having his breasts bound flat while playing the clarinet stifled his breathing and inhibited his performance — if not his spirit.
The talented musician was 17, still at school and coming to terms with being transgender — identifying as a boy despite being born a girl.
Wearing a commercially available chest "binder" — a garment that looks like a tank top to flatten his breasts — allowed him to reduce the amount of gender dysphoria, or distress, he felt about having feminine features. But it also impaired his ability to play the clarinet.
"You can only bind for so many hours at a time. They are very tight. It does restrict your breathing and playing a wind instrument, that's the biggest part," Hugo said.
"I couldn't bind my chest when I played, and I was playing over four hours a day.
"That's a big length of time to have a lot of really intense dysphoria that I can't do anything about. It was really affecting my mental health.
"I would have bad posture while playing because I couldn't bind so I would hunch over and then get told off for having terrible posture."
Before his 18th birthday — and before entering the conservatorium — Hugo had what is colloquially termed "top surgery" — reconstructive surgery to remove his breasts and sculpt his chest.
Supported by his parents, he had the life-changing operation in a private hospital while still a patient at the Queensland Children's Gender Service, which offers medical treatment, but not surgery.
"I saw a private surgeon who specialises in mastectomies for trans-masculine people specifically to make them look as aesthetically male as possible," Hugo said.
"I was really adamant that this was what I wanted, and this is what I needed, in order to treat my dysphoria. It was the main source of my dysphoria.
"I always remember the first time that I realised that my chest was going to change. My Mum was like: 'You're growing up into a young woman.'
"I was somehow really devastated about that. I was really sad that I was not going to have a flat chest anymore."
Hugo required a letter from a private psychiatrist to ensure the decision to remove his breasts was his and he was "in the right mental health" before a surgeon agreed to perform the life-changing procedure.
By the time he began his Bachelor of Music at the conservatorium, Hugo — who did not want his surname published for fear of online abuse — was able to play his clarinet free of the dysphoria that had plagued him for years.
'I felt so out of place'
After having surgery, and as part of the Queensland Children's Hospital-based gender service, he started testosterone injections every three weeks.
Now 19 and on a six-month break from his degree, Hugo struggles with pinpointing when he first identified as being male.
"There's a difference between having feelings and being aware of the feelings and making sense of them," he said.
"I remember as a young child just hating my hair, hating all of my clothes. I never really understood why people were into fashion because I hated all of it.
"When I was made to put on a pink jumper or have long hair tied up in a ponytail or something … I felt so out of place.
"But I'd put on a blank t-shirt and some shorts and be so happy — obviously because it brought me so much gender euphoria, but I didn't realise that's what it was."
In many ways, living as a girl made him feel like an intruder.
When students were asked to split into boys' and girls' groups at school, Hugo would intuitively join the boys' side.
"Everyone would be like: 'Why are you here?'" he recalled.
"I'd be like: 'Oh, I don't know. I just feel like I'm supposed to be here.' I didn't realise there was anything off about it.
"And then I'd remember, and I'd go to the girls' side, and I'd feel so out of place. I don't know how to explain it. It was just sort of feeling like I was isolated from all the other girls."
After years of gender dysphoria and being unsure about what he was experiencing, something clicked the summer break before he started Year 11.
"During the school holidays, I'd gotten to wear whatever I wanted — and I was so happy," Hugo said.
"I was like: I can't put on another skirt ever again in my life."
Without confiding in his parents, he convinced them to buy him the boys' uniform to wear to school, no longer prepared to wear a dress.
That prompted questions from some of his teachers and eventually, the school counsellor asked to see him.
She encouraged him to open up to his Mum and Dad.
"I think it was difficult for them in the beginning … the whole grieving process of: 'I've lost a daughter'," Hugo said.
"But actually, the more open I was with them, the more accepting and receptive they were to that, the closer we became.
"I didn't have to pretend to be somebody else anymore. I knew that I could be myself and share everything. It was a really good choice … not having to pretend to be someone else.
"I was really lucky to have my parents that were really supportive and well educated."
'Mental health problems the norm'
After an appointment with a general practitioner, Hugo was referred to the Brisbane-based gender service. Australia has five such clinics for children and adolescents, one in each mainland state and all based in large children's hospitals.
Hugo was one of 241 new referrals accepted by the Queensland service in 2019. In 2020, the clinic took on 430 new patients and last year, 635 new referrals were accepted — a jump of more than 160 per cent in two years.
Big increases in new patient numbers are also being experienced in Australia's two other well-established childhood gender services — Melbourne and Perth.
The QCH-based service began in July 2017 following advocacy by child and adolescent psychiatrist Stephen Stathis who has worked with gender-diverse young people for more than a decade.
The service employs a team of specialists including endocrinologists, sexual health physicians, speech pathologists, nurses, social workers, child and adolescent psychiatrists and psychologists.
Dr Stathis, the QCH's Child and Youth Mental Health Service medical director, said the waitlist for new patient assessment at the gender clinic varied from 10 to 17 months.
He said a Saturday clinic had recently opened focusing on 15 and 16-year-olds deemed at high risk of suicide and poor mental health due to their gender dysphoria.
"Mental health problems, particularly in adolescents who are trans, or gender diverse, are unfortunately the norm, rather than the exception — there's high levels of anxiety, depression, post-traumatic stress, psychosis and eating disorders," he said.
"Suicide attempts in the trans adolescent community are 20 times higher than 12 to 17-year-olds in the general community in Australia.
"They self-harm at rates that are seven times higher than young people of the same age.
"Acceptance and support by your family, by your school and peers — those are the issues that are most protective in terms of mental health."
With the number of new patients referred to the gender clinic increasing year on year, Dr Stathis said the plan was to develop expertise across the state.
"There's a big focus on tele-health support right across Queensland," he said.
"Although the Queensland Children's Gender Service holds a lot of specialist expertise, we would encourage other hospital and health services across Queensland to treat young people.
"Provided they get a comprehensive, developmentally informed assessment, and they're reviewed by a multi-disciplinary team, there's nothing stopping other hospital and health services also commencing treatment, both medical treatment and psychological treatment. We're here to offer additional support, if required."
Overseas scrutiny
The rise in new patient referrals to the Queensland unit comes amid scrutiny of gender services for children and adolescents in the UK with the controversial Tavistock clinic due for closure next year.
Britain's only dedicated gender identity clinic for children and young people launched more than three decades ago. It will be wound down after an independent review into its practices.
Paediatrician Dr Hilary Cass, who led the review, found in an interim report that having a single, specialist service model was not "a safe or viable long-term option".
It will be replaced with a new provider model through regional centres to be run in conjunction with leading children's hospitals, including London's Great Ormond Street and Liverpool's Alder Hey.
Dr Cass found the rise in referrals to the Tavistock clinic had resulted in overwhelmed staff and waiting lists of more than two years for a first appointment, leaving young people "at considerable risk" of distress and deteriorating mental health.
Her interim report did not provide definitive advice on the use of puberty blockers and feminising or masculinising hormones. Instead, Dr Cass said recommendations would be developed as research progressed.
"Treatment options must be weighed carefully," she wrote.
'There's not one person making a decision'
Dr Stathis welcomed Dr Cass's review, saying gender services in Australia already aligned to her recommendations.
He said all Australian child and adolescent gender clinics were embedded within paediatric hospitals and were actively involved in research as part of a national consortium.
Although Hugo was almost 17 when he first sought medical treatment, Dr Stathis said he had seen children as young as five at the clinic.
"There is, of course, no hormone treatment, when you're a child," he said.
"But when they enter puberty, it's a time of considerable distress and anxiety for them and it's at that time that a decision may be made about whether to commence pubertal suppression."
Last year, 70 patients at the QCH gender service were started on puberty blocking drugs and 83 began gender-affirming hormones.
"The clinic accepts all referrals, but that doesn't mean that patients are quickly going to have their puberty suppressed or be treated with hormones," Dr Stathis said.
"Some young people may receive no medication at all.
"There's a diverse range of young people who come to the clinic and there is a lot of diagnostic rigour and thought about the assessment and treatment plan. For many young people, the comprehensive assessment can take weeks, if not months."
Dr Stathis said the clinic adhered to the Australian Standards of Care and Treatment Guidelines.
"We listen to the young person, and their family, mindful about what is in their best interests. There's not one person making a decision," he said.
"It's the whole team holding the young person in mind.
"This is a complex issue. The more complex the issue, the more important it is to have input from a multi-disciplinary team."
Hugo entered the public clinic after a six-month wait and having already socially transitioned as a male.
He had months of assessments before undergoing a double mastectomy in a private hospital.
"Before 18, there are occasional gender-affirmed males, trans males, who ask for top surgery, which is a bilateral mastectomy," Dr Stathis said.
"That's a process that's not entered into lightly.
"That surgery, though, is not provided at the Queensland Children's Hospital, or anywhere in the public system."
Hugo's surgery was two-and-a-half years ago. The change it has brought still makes him smile.
"It just made the biggest difference to me — for the first time feeling like yourself is amazing," he said.
"Feeling the wind on my back at the beach or feeling the waves on my chest when I go swimming is like the happiest thing for me.
"All of the little things mean so much."
He was keen to share his story as a message of hope to other trans youth, their parents, and carers.
"Despite the lack of representation and visibility, trans people can and do go on to follow their dreams and lead fulfilling lives like anybody else," he said.
"If anything, your experience will give you a unique and valuable insight into the world, which you will always have with you, and I think that is very special."
Hugo has a girlfriend he describes as "beautiful, understanding and endlessly supportive". And he has plans of continuing his studies in the bass clarinet in Europe once he finishes his Bachelor of Music at the Queensland Conservatorium.
After that, he hopes to earn a permanent position with an orchestra and to be seen as "not the trans guy, but as Hugo, the clarinet player".
