Hugo dreamed of studying at the Queensland Conservatorium of Music, but having his chest bound while playing the clarinet choked his breath and inhibited his performance, if not his spirit.
The talented musician was 17 years old, still in school and accepting to be transgender, identifying as a boy despite being born a girl.
Using a commercially available breast “binder,” a garment that looks like a T-shirt to flatten her breasts, allowed her to reduce the amount of gender dysphoria, or distress, she felt about having feminine features. But it also hurt his ability to play the clarinet.
“You can only string so many hours at a time. They are very tight. Hold your breath and play a wind instrument, that’s the most important part,” said Hugo.
“I couldn’t tie my chest when I played, and I played more than four hours a day.
“That’s a long time to have a lot of really intense dysphoria that I can’t do anything about. It really affected my mental health.
“I would have bad posture while playing because I couldn’t tie, so I would hunch over and then get called out for having terrible posture.”
Before his 18th birthday – and before entering the conservatory – Hugo had what is colloquially called “top surgery”: reconstructive surgery to remove his breasts and sculpt his chest.
Hugo had “top surgery” before his 18th birthday. (ABC News: Mark Leonardi)
With the support of her parents, she had the life-changing operation at a private hospital while still a patient at Queensland’s Child Gender Service, which offers medical treatment, but not surgery.
“I saw a private surgeon who specialized in mastectomies for transmasculine people specifically to make them look as aesthetically masculine as possible,” Hugo said.
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“I was very determined that this is what I wanted, and this is what I needed, to treat my dysphoria. It was the main source of my dysphoria.
“I always remember the first time I realized my chest was going to change. My mom said, ‘You’re making a young woman.’
“I was kind of devastated by it. I was really sad that I wasn’t going to be flat-chested anymore.”
Hugo required a letter from a private psychiatrist to ensure that the decision to have her breasts removed was hers and that she was “in the right mental health” before a surgeon would agree to perform the life-changing procedure.
When he started his music degree at the conservatory, Hugo, who did not want his last name published for fear of online abuse, was able to play his clarinet free of the dysphoria that had plagued him for years.
Hugo says he feels like himself now. (Supplied)
“I felt so out of place”
After having the operation, and as part of the gender service at the Queensland Children’s Hospital, he started testosterone injections every three weeks.
Now 19 and on a six-month hiatus from his career, Hugo struggles to identify when he first identified as a man.
“There’s a difference between having feelings and being aware of feelings and making sense of them,” he said.
“I remember when I was a kid I just hated my hair, I hated all my clothes. I never really understood why people were into fashion because I hated everything.
“When they made me wear a pink sweater or have my long hair tied in a ponytail or something… I felt so out of place.
“But I’d put on a white T-shirt and shorts and I’d be so happy, obviously because it brought me so much gender euphoria, but I didn’t realize that was it.”
Hugo was born a woman, but felt he never fit in. (Supplied)
In many ways, living as a girl made him feel like an intruder.
When students were asked to divide into boys and girls groups at school, Hugo intuitively joined the boys’ side.
“Everyone would say, ‘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 realize there was anything outside.
“Then I remember, and I’d be around the girls, and I felt so out of place. I don’t know how to explain it. It was kind of like I felt isolated from all the other girls.”
After years of gender dysphoria and not being sure what I was experiencing, something clicked in the summer break before Year 11 started.
“During the school holidays, I got to wear whatever I wanted, and I was very happy,” Hugo said.
“I said, I can never put on another skirt in my life.”
Not trusting his parents, he convinced them to buy him a boys’ uniform to wear to school, no longer willing to wear a dress.
This prompted questions from some of his teachers, and eventually the school counselor asked to see him.
She encouraged him to open up to his mother and father.
“I think it was hard for them at first … the whole grieving process of, ‘I’ve lost a daughter,'” Hugo said.
“But really, the more open I was with them, the more accepting and receptive they were to it, the closer we got.
“I didn’t have to pretend to be someone else anymore. I knew I could be myself and share everything. It was a really good choice…not having to pretend to be someone else.
“I was very lucky to have parents who were very supportive and well educated.”
Hugo identifies as trans and is on a six-month break from his music degree at the Queensland Conservatorium. (ABC News: Janelle Miles)
“Mental health problems are the norm”
After an appointment with a GP, Hugo was referred to the gender service in Brisbane. Australia has five such clinics for children and adolescents, one in each mainland state and all located in major children’s hospitals.
Hugo was one of 241 new referrals accepted by the Queensland service in 2019. In 2020, the clinic saw 430 new patients and last year 635 new referrals were accepted, a jump of more than 160 per cent in two years .
Large increases in new patient numbers are also being experienced at Australia’s two other well-established children’s 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 youth for more than a decade.
The service has a team of specialists that includes endocrinologists, sexual health doctors, speech therapists, nurses, social workers, child and youth psychiatrists and psychologists.
The Medical Director of the Queensland Children’s Hospital Child and Adolescent Mental Health Service, Dr Stephen Stathis. (ABC News: Janelle Miles)
Dr Stathis, medical director of QCH’s Child and Youth Mental Health Service, said the waiting list for new patients to be assessed at the gender clinic varied from 10 to 17 months.
She said a Saturday clinic focused on 15- and 16-year-olds who are considered to be at high risk of suicide and poor mental health because of their gender dysphoria had recently opened.
“Mental health problems, especially in trans, or gender diverse, teenagers are unfortunately the norm, rather than the exception: there are high levels of anxiety, depression, post-traumatic stress, psychosis and eating disorders,” she said. .
“Suicide attempts in the trans adolescent community are 20 times higher than 12-17 year olds in the general Australian community.
“They self-harm at rates seven times higher than young people of the same age.
“Acceptance and support from your family, school and peers – these are the most protective issues 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 is a huge focus on telehealth support across Queensland,” he said.
“While the Queensland Children’s Gender Service has a lot of specialist expertise, we would encourage other hospital and health services in Queensland to treat young people.
“As long as they receive a comprehensive and developmentally informed assessment, and are reviewed by a multidisciplinary team, there is nothing to stop other hospital and health services also starting treatment, both medical and psychological treatment. We are here to provide additional support . . , if necessary.”
Scrutiny abroad
The increase 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 set to close next year.
Britain’s only dedicated gender identity clinic for children and young people was launched over three decades ago. It will be canceled after an independent review of its practices.
The Tavistock center will close next year.
Pediatrician 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 by a new provider model through regional centers which will be run jointly with leading children’s hospitals including Great Ormond Street in London and Alder Hey in Liverpool.
Dr Cass found that increased 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 anxiety and deteriorating mental health.
Their interim report did not provide definitive advice on the use of puberty blockers and feminizing or masculinizing hormones. Instead, Dr. Cass said recommendations will be developed as research progresses.
“Treatment options must be carefully weighed,” he wrote.
“There is no one person who makes a decision”
Dr Stathis has welcomed Dr Cass’s review, saying gender services in Australia are already aligned with her recommendations.
He said all Australian child and adolescent gender clinics were embedded within pediatric hospitals and were actively involved in research as part of a national consortium.
Hugo says his family was “cooperative and polite”. (ABC News: Janelle…