For two years, Nick Dyball felt he was keeping a secret from his family.
"Trapped is probably the first word that comes to mind," the now 17-year-old said.
At nine years of age, he finally told his parents he was transgender.
"Having that conversation was like having that weight taken off me."
The change in Nick's demeanour was immediate, his mother Rachel Cunnen recalled.
"I remember very clearly that it was like there was a palpable weight that just lifted off him — he was dancing around after that," she said.
The conversation triggered a flurry of activity. Nick's pronouns changed and Ms Cunneen assumed the role of advocate, helping her son to navigate Canberra's health system — a task she described as "like a full-time job".
"It wasn't as if there was somewhere I could go to access everything," she said.
"It was this wandering path to work out what was available, what might be important and how people could help us to navigate this thing."
The ACT government recently released its LGBTIQ+ Health Scoping Study, which highlights the serious barriers that transgender and gender-diverse Canberrans, especially young people, face when accessing health care.
"A shortage of available primary care professionals, including GPs, mental-health supports and paediatric specialists with an understanding of LGBTIQ+ health needs have exacerbated the issues faced by the LGBTIQ+ community," the report says.
"This has resulted in significant gaps in health care for LGBTIQ+ people in the ACT … with excessive wait times, delays from referrals and high costs associated with interstate and international travel."
Where to after coming out?
When a transgender person comes out, their first port of call is usually a general practitioner.
But finding one in Canberra who is willing to treat transgender patients isn't easy.
A handful of doctors passionate about this area of medicine do the bulk of the work. Among them is Clara Tuck Meng Soo.
Demand has grown exponentially in recent years, to the point Dr Soo has closed her books to ensure her patients don't wait more than a month for an appointment.
"We're seeing a year-on-year increase of 20 to 30 to 40 per cent," she said.
Yet the pool of doctors open to treating transgender patients in Canberra hasn't grown.
"I think a lot of GPs feel that they haven't got the experience or training to work in this area but, in fact, it's not that difficult," Dr Soo said.
"It's like any other area of medicine, we learn as we go along."
For young transgender people, puberty blockers can be an important step towards gender affirmation.
Yet there's only one paediatric endocrinologist in the ACT who can administer them.
Nick first started seeing that specialist seven years ago, when he was 10.
"In the beginning, it was great — I was one of only a few trans-kids," he said.
"It was very one-on-one. We would sit and chat, we'd talk about my life, we'd catch up and then we'd get all the gritty stuff out of the way.
"It felt like very personal care and that was really important for me, especially back then when I was feeling very alone at times."
But as demand grew, the level of care Nick received changed.
"It became a lot more difficult — once I waited in the waiting room for four hours for a five-minute check-up," he said.
"I felt quite disregarded and I didn't trust my doctor as much as I once did."
According to the scoping report, 20 young transgender people are on the waitlist of Canberra's only paediatric endocrinologist.
Dr Soo said some patients waited a year for an appointment.
"For a child who is actually going through puberty, where physical changes are happening very quickly, a year can make a big difference," she said.
"Those changes can be irreversible, so a child who is suddenly faced with that can find it very distressing."
Limited access to medical professionals
Jenni Shoring is a proud transgender woman.
The 42-year-old started hormone treatment on her 40th birthday and says transitioning saved her life.
"The dark days are well and truly gone," she said.
"I really see the world in colour as opposed to grey or black and white. Everything is so much brighter."
Ms Shoring turned to A Gender Agenda — a community organisation that supports the intersex, transgender and gender-diverse community — for help navigating the health system after she came out.
She is now the organisation's operations manager and is reminded daily of how the system is failing trans children.
Ms Shoring described the wait times to see Canberra's paediatric endocrinologist as "horrifying" and said mental-health support was grossly insufficient.
And that's in the private sector.
In the ACT's public system, there isn't a single paediatric psychiatrist available to treat patients who are under 18.
The ACT report acknowledges that the ideal response would be to simply employ an extra paediatric endocrinologist and psychiatrist, but says "those specialists would need to be suitably trained and have a sympathetic attitude towards treating transgender patients".
It adds that Australia currently faces a shortage of both.
Mental-health support was essential, according to Nick.
He admitted he was lucky finding his therapist after coming out — cost wasn't a barrier and therapists weren't as inundated then as they are now.
"If I hadn't gotten that, sorry to say it but I would be dead," he said.
"It's so important. It's everything."
A spokeswoman for Canberra Health Services says its executive director of Women, Youth and Children, Susan Freiberg, is leading the design of a new care model, which will better support transgender patients and their families.
"The new model of care will provide multi-disciplinary treatment," the spokeswoman.
"It will provide patients and their families with holistic support from specialist allied health, nursing and mental health team members in addition to medical specialists."
The new model is expected to be implemented next financial year.
Community hub needed to connect services
Advocates say the community needs a gender hub: a centralised point that connects all necessary services.
"It would be huge," Ms Shoring said.
"It would give people a clear pathway in."
Ms Cunneen echoed a similar sentiment.
"Parents need a hub — they need a point they can go to where there's good mental-health care and information, medical advice and medical treatment.
"They basically need all the professionals to coordinate that for them."
That's what the gender service at the Royal Children's Hospital in Melbourne has offered transgender Victorians since 2003.
When it first opened, the service was receiving one referral every two years.
Last year, 821 young transgender patients were referred to it.
"Victoria has been extremely fortunate with our state government that they've supported us not just with resources in terms of funding, but they've also invested in creating the systems across primary and secondary care so that we can meet this demand," the service's director, Associate Professor Michelle Telfer, said.
"Victoria really has pushed forward in leading the country on provision of this multi-disciplinary collaborative care and what we're seeing is that it's producing great outcomes.
Dr Telfer is confident the model could be replicated in the ACT.
"The system is not sustainable with individuals working separately — the system requires coordination," she said.
"But you can't do it without state government support — that is an absolute."
The ACT scoping study highlights that the ACT is "the only jurisdiction not to have a comprehensive gender-focused health service available either in private practice or through a publicly-funded gender clinic".
It says such a service is a high priority but concedes it "may only be achieved over a number of years".
The transgender community had waited long enough, Dr Soo said.
"If we are to live up to our moniker of the 'capital of equality', more needs to be done now."
