When Olivia* was just 18 months old, she had already begun rejecting stereotypical boys' toys and clothing.
By the age of two, she started asking questions, such as, "When will I get a vagina?"
And Olivia, born natal-male, was three-and-a-half years old when she met Dr Stephen Stathis, whose gender clinic, which is now at the Lady Cilento Children's Hospital has just received a life-saving funding boost of more than $1 million to reduce wait times for children.
Olivia is now nine years old and the youngest child of three, with two brothers.
Her mum, Rachel*, said Olivia was a very sad child and would rip off her clothes.
"You'd take her shopping and she'd run to the girls' department and just grab stuff and just hoard it," she said.
Olivia, originally Samuel*, would get very physical, biting and hitting, and when they went to their GP, the family was referred to Dr Stathis, who at that time had begun an unofficial "clinic" of sorts, in his own time.
"It was a six-month wait and that was horrifying because we didn't know what to do," Rachel said.
"We always heard it's a phase, it's a phase, it's a phase."
Rachel said her child's behaviour was sometimes almost primal.
"Even patterns on the sheets - she would end up ripping them off the bed in a frenzy, not acknowledging if boys even existed," she said.
"Putting on a pair of shorts, Samuel would put two legs in one hole and put the other hole down his back so he had a skirt on.
"We were prepared for Stephen to say, look, you're crazy, or it's all you, you want a daughter.
"But what he said was Samuel was classified as what's called gender variant behaviour."
Rachel said Dr Stathis gave her information and statistics on how many children would desist and live as their natural gender or develop a sexual orientation that was not heterosexual.
"Our child was three-and-a-half years old and we were being prepared for our child to be gay or transgender or no gender, suicide, self harming, we were being given lots of avenues that this could go down," she said.
Rachel said the school was wonderful and diverse in their thinking, with her Prep teacher giving Olivia the time to be a child in an environment without gender.
"School was a very gender-oriented place - girls' bags, boys' bags, girls' lines, boys' lines," she said.
By the end of Prep, the family decided to allow her to start wearing dresses outside the home.
But Olivia decided to tell her classmates on her own.
"Our plan was that she would go back to Grade 1 as Olivia, but obviously she just couldn't wait," Rachel said.
"She sat the class down one day and told them she had something to say and that she was now Olivia."
Rachel said once the transition happened, Olivia had a "euphoric" feeling but it went in cycles.
"She really feels that she's waiting for someone to say something to her, she fills with huge levels of anxiety," she said.
During her last appointment, Olivia asked if she could have a womb transplant.
During the Christmas break, a girl started her menstrual cycle and told Olivia "what a girl is".
"Olivia is now in that grief cycle of loss, understanding that she will never ever be what she considers is a real girl, yelling and screaming, projecting anger at people," Rachel said.
"What happens is that I can't put her two brothers to bed properly because by the time I get to them, they're asleep."
Rachel said she and her husband went through feelings of "grief" of the loss of a child.
"But you feel you have no right to grieve because you have this child, and you have all these mementos of Samuel but all of a sudden you're not allowed to display them anymore," she said.
"How do you maintain the connection to the past when your child doesn't want you to?"
Rachel said many people did not understand, and they put on "masks" to go to work: "They don't know what we deal with when we come home".
"Life isn't good right now. You don't want to give that impression that they transitioned and everything is great - because it's just not."
But Rachel said the funding from the Queensland government was vital as it meant faster access to specialists.
"Families need it, you are lost, you are grieving, you are trying to find out where to go next," she said.
"That extra funding and getting more support up there for families to access quicker is the difference between good mental health and bad mental health."
How did the clinic start?
About half a decade ago, the clinic started organically after Dr Stathis, then in a consultation liaison role at the Royal Children's Hospital, started getting referrals of children and adolescents who were gender dysphoric or who had gender variant interests and behaviours.
He said the numbers started to rise and so he developed his own "clinic", which was not funded, with paediatric endocrinologist Professor Jennifer Batch, in their own time.
Dr Stathis would see clients about four hours a week, referring people who met the criteria for hormone treatment to Professor Batch, for her monthly clinic.
"Once I developed a name that I was interested in this area, suddenly I started to get many, many referrals," Dr Stathis said.
About three years ago, the number of clients started to climb "significantly".
"To the point where in November last year, I had a two-year waiting list for me to see young people," Dr Stathis said.
"And then the waiting list continued. The numbers were growing by about 25 per cent per quarter."
The wait time to then see Professor Batch was about nine months, meaning it was almost a three-year wait from when Dr Stathis received a referral to when a young person could start medical treatment.
"We had over 70 young people just on the wait list [late in 2016]," he said.
A gender clinic was formally set up at the Lady Cilento Children's Hospital in recent months, with regular mental health assessments every Friday, with recurrent funding meaning permanent staff can be hired.
Dr Stathis said he expected more people to come forward after hearing the wait time was reduced.
Are all the people who present to the clinic transgender?
But Dr Stathis said not all young people he saw were gender dysphoric, with some gender variant.
"Numbers of young people were getting their sexual identity mixed up with their gender identity."
"There's so many different terms, gender diverse - their interests and behaviours were not falling between what we would call cultural norms," Dr Stathis said.
Dr Stathis said girls could do "stereotypical boys things" and were called a tomboy.
"But boys, you put on a pink tutu and you're off to see the doctor," he said.
"There's a lot of cultural norms here which makes it very complex."
Dr Stathis said many of the young people he saw were very distressed, had mental health problems and were suicidal.
"Many of these young people were just gender variant, they didn't identify as the opposite gender, they just like to do things that the opposite gender likes to do," he said.
"A little boy would say to me, 'Dr Steve, I like playing with dolls and I like fairies and I like dressing up, but I'm still a boy'. That's not gender dysphoria."
Dr Stathis said he occasionally saw young girls who had been sexually abused, who said, 'I want to be a male'.
"In their view, if they were only a male they wouldn't have been sexually abused and they would have been protected," he said.
"The treatment for that is not hormone treatment, the treatment around that would be treatment around sexual abuse."
Dr Stathis said other adolescents almost saw it as a "lifestyle choice", with no evidence of being truly transgender.
"It became really, really complex."
Why is the wait time important?
Dr Stathis said if a young person wanted treatment at the age of 12 or 13 and were at the start of puberty, it would previously take them three years to get medical treatment.
"The evidence is for those children and adolescents who are gender dysphoric, early medical and mental health treatment significantly reduces long term medical and psychiatric morbidity," he said.
"Children who are gender dysphoric, about 40 per cent would screen positive for mental health issues.
"Adolescents, up to 90 per cent screen positive for depression, anxiety, suicidal behaviour, self harm."
Dr Stathis said he had seen horrendous things, such as children wanting to cut off their penises, adolescent girls trying to cut their breasts and girls binding their breasts with duct tape because they were so distressed by their development.
"When the duct tape comes off, the skin just gets ripped off," he said.
Dr Stathis said some children were so distressed by their genitals they could not touch or wash them, causing "horrible fungal problems, their hygiene is so poor."
He said for some girls, the thought of touching their genitals was so offensive, they could not use pads, let alone tampons, and instead tried using pull-up nappies that leaked and smelt.
"They don't go to school, truly the most horrendous thing.
"And then I've seen it, once you just listen to these young people, once you believe in them, once you take them seriously and then treat their medical problems, many of their mental health issues go away."
But Dr Stathis said it was tough and some mental health problems did not go away completely.
Other desperate young people bought medication or testosterone illegally online or asked a female friend to give them the birth control pill, both of which could have serious side effects, and if they were self treating, they may not necessarily be transgender.
"There may be other issues going on and that needs to be worked through," Dr Stathis said.
Children's Health Queensland Hospital and Health Service will receive $1.117 million over four years to reduce patient wait times at the Lady Cilento Children's Hospital gender clinic as part of the government's $5.27 million Sexual Health Strategy.
A key focus will be to reduce patient wait times regarding access to endocrine treatment.
Dr Stathis said early treatment with hormones could reduce long-term physical effects, such as the "male look" that many people had if they were treated late in life.
He said the funding meant the wait time could be reduced from about three years to three months.
What happens if you present to the clinic?
A referral to the clinic usually comes from a GP or specialist.
Dr Stathis said the process included a full mental health assessment, follow-up consultation with the young person, their family and community, a referral to a second psychiatrist to confirm the diagnosis and eventually might include a referral to an endocrinologist.
Dr Stathis said for young people who were gender dysphoric to receive hormone blockers, they first needed to demonstrate they had socially transitioned for a minimum of six months.
"They live as their preferred gender, or the 'real life experience'," he said.
This includes dressing as that gender, being addressed as "she" or "he", possibly changing your name and using the correct bathroom.
If they received a referral to an endocrinologist, they would be examined to make sure there were no medical reasons they could not receive treatment.
If at the stage of puberty, they could start on a pubertal suppression drug called Lucrin, which would either block testosterone production if they were male, or estrogen production if they were a female.
They will grow normally, but stop developing secondary sex characteristics, although it is reversible and can be stopped at any time.
The age they receive Lucrin depends on the age that puberty begins.
Lucrin costs more than $1000 an injection, and is given every three months.
Young people stay on Lucrin until about 16 years old, unless they want to stop.
Once they reach 16 years old, they need the approval of the Family Court to receive hormone treatment - estrogen or testosterone - which could cost up to $15,000 in legal fees.
But the hospital is unusual in Australia in that it absorbs the costs of Lucrin and the court costs.
Dr Stathis said the majority of people who present do not need treatment.
"About 75 per cent of boys and girls who present with gender variant interests and behaviours, or who are gender diverse, will desist," he said.
"You might get a six or seven-year-old girl wanting to dress as a boy. She may even say she wants to be a boy. When she hits puberty, she says 'no, I'm just a girl who likes to do boy things'."
Sex reassignment surgery is illegal under the age of 18 and surgery is not recommended to young people.
This clinic also helps work with schools, churches, clubs and extended families to address issues such as which toilet to use, swimming carnivals, uniforms, names at schools, passports and licences.
* Pseudonyms have been used for the privacy of the children involved.
