Should I Delete That? - Gender surgery saves lives… with Mr James Bellringer

Episode Date: March 30, 2025

Mr James Bellringer is a surgeon who specialises in gender surgery in transwomen. James has been doing gender surgery since 2000 - and in this conversation, he discusses what the climate around gender surgery was like when he started and how he sees it now. He tells us about his experiences of the transformative effects of gender surgery, how vital it is for the mental health of his patients, and how he feels the treatment should be managed appropriately. This episode was recorded in November 2024 If you would like to get in touch - you can email us on [e-mail] us on Instagram:@shouldideletethat@em_clarkson@alexlight_ldnShould I Delete That is produced by Faye LawrenceStudio Manager: Dex RoyVideo Editor: Celia GomezSocial Media Manager: Emma-Kirsty FraserMusic: Alex Andrew Hosted on Acast. See acast.com/privacy for more information.

The majority of trans people, they don't do this because they want to. In the end, they've got no option. Hello and welcome back to Should I Delete That? Today's guest is Mr James Bellwinger. He's a surgeon who specialises in gender surgery in trans women. So James has been doing gender surgery since 2000 and he's a real expert in his field. In this episode, he and M dive into how his work has evolved over the last 25 years. They talk about the life-changing impact that he sees in his patients and just how essential this surgery, gender surgery, is for people experiencing gender dysphoria.

Frustratingly, because I was really looking forward to being part of this conversation, this episode was recorded on the day that I'd lost my voice, so it's just M on hosting duties. And she and James have a really open conversation. They unpack some of the buzzwords that often crop up in conversations around trans issues in the media. And James offers a unique perspective as a surgeon, and it's one that highlights the profound and positive effect that this surgery can have and does have. It's a fascinating listen, and we really hope you enjoy it. Here's James.

Hello, doctor. No, Mr. Hello, Mr. James. Bellringer. Thank you so much for coming in. I saw I said this to you before we started recording but I saw a clip of you on TikTok funnily enough a few months ago

speaking about gender dysphoria and I thought it was so interesting but the thing that I love the most and again I've already said this to you off air was the comments it was a it was a loud Bible video and had half a million likes and it had thousands of comments

that was so positive and it was one of the best comment sections I've ever seen in reaction to a conversation around transgender issues. So I was desperate to talk to you for the podcast. We're very surprised, undelighted that we found you and that you said yes. So thank you so much. If it's all right, it would be amazing to get a little bit of background to you

and how you got into this field of medicine. I was a surgeon. I still am a surgeon. I qualified as a urologist and started work at West Middlesex Hospital. but I had one session of my week working at Charing Cross where gender surgery has been done for since 1967 I think might be 68 but it's a long time I was quietly unaware of that really

I knew it was being done there but it wasn't anything I was going into and the guy who was doing it there announced he was going to retire and so they started looking around was there they had on the books who could do this. And they came to me and said, are you interested? I said, yes. It took me a little longer than that. I mean, I felt this was a decision I couldn't make on my own.

So I had to talk to my wife. She was actually quite supportive. And I had to speak to the kids and say, what happens if your kids, if your friends at school find out that dad's doing sex change operations in inverted commas. It's not, I'd be cool, that'd be fine. So I said yes and got trained and I've been doing it for the last 25 years. Wow.

What was the landscape like for that conversation at the time? Slightly more difficult than now probably. Things have moved on a bit. People are more sort of prepared to accept people being different. And I think the trans community has ridden the way. of gay rights, gay pride. But, I mean, when I was at school, if there was one of the boys had said,

you know, I quite like the idea of having sex with other boys, that wouldn't have gone well. No. But both my sons had friends who were at least temporarily dabbling in the gay life. My daughter certainly had friends who were, lesbian. I mean. Yeah, different world. And it is different world, much more acceptance of it. And I think it has become slightly easier, which is why I suspect the numbers are ballooned. Yeah. Because when I started out doing it, you had to be absolutely totally determined. Yeah.

Nowadays, I think it's got a little easier to come out and be different. Yeah. And if that includes saying, although I look like a man, I think I'm a woman. Or I believe I'm a woman. Or I believe I'm a woman. and I think that's become easier. I wouldn't have known that these surgeries that being not done in Charing Cross Hospital, for example, I think we, like you say, it's become a lot more mainstream because it's become a conversation, it's become an easier conversation. How has that been reflected over the last 25 years in the patients that you've seen? They've got younger.

Have they? I think the average age of patients I was operating on when I started 25 years ago was about 45 to 50. it's certainly younger than that now I mean I've had a few in their late teens early 20s they worry me a bit more than the older ones yeah well you change a lot

between 18 and 30 yeah that's a big part of conversation yes you're told you're referring psychiatrists psychologists gender specialist tells you this all stacks up it's all fine when you're looking at something who's 18, 19, 20,

thinking, how much did I change between 18 and 20 and 30 at an awful lot? Yeah. So they've got younger and there's much more, a lot more of. Yeah. I'd like to talk about the fact

they've gotten younger and because I think that it's a whole conversation kind of that's happening quite mainstream. But I think it's also interesting and something we perhaps don't consider because when we think about trans issues at the moment or the trans conversation at the moment,

we are speaking about it so much in the context of young people, it seems unusual that people would be in their 40s and 50s, but that was... And beyond that, the oldest patient I've operated on was 85. Wow. That's kind of beautiful that you got to give them that. Yes, I mean, and that was a classic story. Patient was actually a Hungarian immigrant came over in the 50s. Met and married a British woman.

Yeah. They didn't have children, which isn't that much of a surprise. But people conformed in those days. You did what you were expected to do. So you went and found somebody of the opposite sex. You got married. You had babies usually. Yeah.

Because that's actually what was expected. You know, the 2.4 children, mum stays at home and dad goes out to work. And it was the sort of nuclear family. That's all blown nicely apart. That's a good thing. That is a good thing. But they conformed. They did what was expected of them.

And the older group quite often, like this patient, the wife died. So there this patient was in the marital home. And instead of collecting her clothes up and throwing them out through what had been his clothes out and started wearing the other ones and came forward. And basically said, I always knew this is what I wanted to do. she's not there okay I'm prepared to do it but I would never have done it while she was alive because she'd be so upset okay I suppose it's it in being true to yourself you might be betraying someone else a little bit the operation isn't great on relationships no why is that do you think well I think I remember I have a patient years ago who I said you know she said

I'm going to stay together with my wife we're going to hang and staying at the house you'll be lucky she said no no we will we will we will it everything will be fine and i saw her a couple years later and she said you were right you know and she said that the wife had said i still love you but i'm not ready to be a lesbian yeah which is you know the the the the male genitalia had gone yeah so there was no prospect of heterosexual sex yeah and And she didn't fancy having sex with somebody you didn't have a period. So when you're seeing people in their 40s, 50s and beyond, are they generally divorced or is it, have they tried living a certain kind of life and they want something else?

A number of them have separated, a number of them are divorced, a number of them are trying to keep it together. Yeah. But the operation is a big thud. I think quite a lot of the wives think, well, maybe it'll be a right. maybe we will stay together and then the operation's done and you're not just dealing with somebody you didn't think who says they think they're a female and so on and so forth,

but they still love you, blah, blah, blah. You're now doing with somebody who's got female genital anatomy. Yeah. And that's, I think it's a hammer blow for a lot of them. I don't know, I don't know the absolute answer, but I think those are amongst the reasons. Yeah. I'm a surgeon, not a psychologist.

Yeah, of course. So going to the fact that they are getting younger, and this is a conversation that's being had among the government, like, I mean, sort of front and centre at the moment because the government are having it, about how old you should be before you can access treatment for gender dysphoria or... Well, treatment in the sense of psychological support, counselling and so on.

I think if you've got a child who expresses a parent gender dysphoria, You have a duty to support them and support their mental health and just give them an intense counselling. The difficulties when it comes to giving things like hormones, there's this idea that giving hormones is reversible. Well, it's not entirely. Okay. I mean, if you're looking at a baby boy

in the uterus around sort of, during development, very high levels of testosterone. Then they're born, the testosterone goes down to squat dizzily until puberty. Then they get this huge mass of testosterone coming out again. And testosterone, I mean, steroid hormones do affect the brain. And what worries me about starting hormones is, are you preventing that second rush of testosterone, which might then get them to say, actually, I'm all right being a bloke.

Okay. And there's some evidence for this. What age is that? Well, puberty is 12 to 15, 16, isn't it? Yeah. So it would be, the argument there would be that children under 16 shouldn't be able to access. There's no line because they check. There's variation, isn't there?

I mean, some people don't actually hit puberty until they're 15-ish. And some kids are beginning to shave at the age of 11. Well, not the girls, but you... As part of that distinction, where are we currently at with where you can access? Well, at the moment, hormones are a no-no unless you go privately, and they're trying to block that off as well. Okay. I think it's probably the right way. Okay.

I do get that there's a lot of distress. I mean, if you think you're a girl and your penis is growing and you're starting to grow hair, over your face and your voice is beginning to break. I get there can be a lot of distress. Yeah. But I think there should be a certain level of pubertal development you get to before they say, no, all right, fair enough. You'll still set it.

But you can't put an age on it. Therein lies a problem. Yeah. Take a step back and look at gender dysphoria because that's, I think, what a lot of people don't, there's a huge lack of conversation around what that is. And the fact that the people who, trans people, first experienced gender dysphoria, they do not associate with the sex that they were born as. No, they've got this certainty that the body they are in is wrong.

They've developed the wrong way. They should have developed as the opposite gender. Or, I mean, the non-binary is a different crowd altogether. They're relatively new in terms of people treating them and certainly new in terms of operations being done. Because I can sort of, if I see somebody who's got male anatomy but thinks they should be a woman, I've got an idea what they might want in terms of genitalia. Of course, yeah. Non-binary, what are non-binary genitalia?

Is it the action man look? Yeah. Or is it somebody as people are starting to ask for who keep the, penis and have a vagina more difficult but the non-binary crowd are they're relatively new and we are we are to some extent feeling our way with them but the straightforward in inverted commas there's nothing straightforward about any of it but the the the trans person who genuinely believes they're the other gender I stuck give us an insight into that in any way obviously you know you've

not experienced it yourself but as you have seen it in your patients and you understand the science of gender dysphoria. You say that, but I still occasionally think, what? Yeah. You know, it still sometimes absolutely amazes me that anybody would do this. I have these moments. I shouldn't say that really. You know, all by patients, I'll think, oh, my God, he's terrible.

No, I still get these moments when I'm thinking, what the hell am I actually doing here? Mm. But you see people change overnight. When I remember a patient who was almost mute when she came into hospital, quiet as a church mouse. And the day after the operation, I went to do my ward drowned. And she was sitting on the edge of her bed holding court with about five or six other people. You think, how did that all get suddenly unblocked? But just the presence of a penis and the lack of female genitalia was just stopping her doing.

Yeah. So she became who she was supposed to be. As she saw it, yeah. And that's actually what matters, isn't it? Yeah. If you've got something genuine in your head, I mean, I think the majority of trans people, if someone came up with a tablet that said that you know there's this trans woman in her 20s life's pretty miserable if someone came up with a tablet that said actually yeah I'm very happy

being a bloke now they take it yeah they don't do this because they want to no they've got in the end they've got no option they have to you know I they come into hospital and I show them a really scary consent form you know this can happen, this can happen, this can happen. And they say, well, I've got to do it. Yeah. I don't want to do it, but I know I have to. Yeah.

They're driven. That makes gender dysphoria as serious a condition as anything. Well, yeah, I mean, it's somewhere in, it's not a mental illness. That's the thing people think of these, they're all mad. It's not really a mental illness. The brain's just wired up differently. What does it class? stance? It's moved, I think, and the Americans, I think, have moved it into intersex.

Okay. They've moved it out of mental disorders and into intersex, and I think that's probably where it belongs. You've got, I mean, you've got the sort of standard intersex with a child that's born, you know, comes out and the midwife says, it's, um, it's, um, not sure. Yeah. And that, yeah, that's. Which in itself can be, can be, that, that, they're an interesting group actually. But this is a group where they come out and the midlife says it's a boy or it's a girl, but the brain isn't there.

The brain doesn't agree. That's a very strong organ, the brain. It'll override everything else. A hundred percent. If gender dysphoria is left untreated, what do you see? We think from the studies that are done, unfortunately there's not that many of them. that if you don't offer any treatment or support for patients with gender dysphoria, about one in five commits suicide.

Okay. That's a very high mortality rate. It is. That's as high as... It's the same as anorexia nervosa if left untreated. Okay. If you allow the patient to starve themselves to death, they will. Okay.

And we know we had a significant number of suicides during COVID because the whole thing just stopped. Okay. So the evidence is there. Yeah. The debate, I suppose, is around appropriate management of this condition or appropriate treatment. To your mind, what is that? To start off with sessions with an appropriately trained person who can unpick the whole thing and to support them and to help them that way.

And then you go on to physical treatments, initially hormones. And then if still required surgery. The hormones done after puberty, taken after puberty, did they reverse? How do they work? Well, they don't reverse anything that's happened. So if you are a trans man who's developed breasts, you're not going to shrink them. They're going to stay. You can't undevelop them.

Hair growth. I mean, you don't start growing hair on your beard and all the rest of things. it alters the follicles so that I mean you might find this surprising but you've probably got the same number of hair follicles on your face as I have that is surprising but they all produce tiny fine downy hair but those hair follicles then change to produce the coarser hair that gives me a beard if I don't shave okay um so taking them taking hormones would shrink won't check won't change the follicles back again okay your voice breaks if you get testosterone and it breaks for women, trans men who take testosterone,

their voice will also break. The changes in the shape of the larynx and the vocal folds aren't reversible. Okay. So what do they do? What can they? I mean, for a trans woman who has their hair follicles with thick hair, does it stop the hair growth? No, hormones don't change it.

They need permanent hair removal, electrolysis, laser. See, that's what I think people don't realize. When you said, you know, if they could take a pill to not have to do all of this, like that's what people are having. There's so much more to it even than... I'm sure that the majority of my patients would rather have grown up

without having to do any of this. Yeah. Because never mind the huge expanse of things you need to do, the cost that's associated. It's cost neutral. Can you explain the cost neutrality on this? I can't quote the paper, but I should be able to, but I have seen it. Somebody did a study looking at trans patients undergoing surgery,

and they move dramatically up the socioeconomic scale after they've had their operations. So they pay more tax. So they're paying for themselves? And they actually end up paying, as a group, they end up paying for their operations. Wow, okay. So actually this is cost neutral. I mean, you know, Rachel Reeves doesn't need to worry about the cost of doing this because actually it pays for itself.

Okay. She's going to get more income tax in. Yeah. So it's proven to actually be an investment in a sense. It's a strange argument, but it's one that does stack up. Yeah. But before we get to that, before people get their operations, appointments on the NHS, what I see from the conversation of the trans people,

that I follow online and that I'm friends with, is that it's very difficult to advocate for yourself and it's getting harder within, like, making appointments, being taken seriously. What's that, what's the sort of state of affairs on that front? Well, within the NHS, you have to put everything through your GP. Yeah. Pretty much. There's a significant number of, should we say, non-believer GPs? No, of course, that doesn't.

This doesn't exist. You're as being stupid. Go away. So they get bounced off by the GP. If the GP's more sympathetic and more reasonable, they get referred. Good. There's currently a three to four year weight on the NHS to be seen in a gender service. Okay.

That's a very long time when you're looking at a one in five. It's a little over the 18-week target. Jesus. You know, if you are 18, 19, 20, and you're looking at your life in front, of you and you're thinking, okay, I've been referred to the gender identity clinic. Four years. Four years when you're 20-something is... Huge.

It's a huge. It's a fifth of your life. When you're an old get like me, it's a little easier to cope with. Yeah, so it's a really long stretch. And you're doing so to have got to that appointment in the first place, you are in a place of desperation or unhappiness. Well, you're very unhappy, otherwise you wouldn't have come forward. Of course.

If you could cope with it, internalize it and just keep going in some. ways you might do it yeah but you've got to the point where I can't do this I want to talk to somebody about it so you're waiting four years three and four years a lot of people are opting to go private but that's incredibly expensive yeah I don't know how much the psychiatrist or psychologist psychiatrists are charging to see patients privately because it's not what I do yeah but it's not cheap and the course if you go privately you're also paying for your own hormones. Of course, yeah.

And estrogens are very expensive. Yeah, it is. And the blocking injections, they usually weigh in around 253, 300 quid a pop. Wow. If you're getting treated on the NHS, is that something that's paid for by the NHS? You pay a prescription charge for them if you're,

but most of the patients are actually on, they've got a season ticket. Okay. So they get their hormones for the price of their season ticket, which are cheaper. Okay. But people who are having to go privately because they're being made to wait three or four years having to pay for themselves. Yeah. This is and, yeah, that, I mean, the cost. And then, of course, paying for the surgery privately presumably as well.

Well, they can't come from an NHS operation on the basis of a private referral. Oh my gosh. Okay. So if you go down private room. You can't, you can't, well, that is actually fair. Yeah, it is fair. I didn't think of that. You can't jump the waiting list by going privately. If you've been assessed privately and have a private referral, you have to pay for your operation. Okay. So that's the decision people are making.

It's not just the consultation. It's not just the blockers. They've got to... If you went privately... Sorry, this isn't really your area, but I'm just curious now, if you went privately, got the blockers in the meantime paid for them yourself

while still waiting for that three-year appointment on the NHS. Would that be an option? In the sense that if you see somebody good privately, they'll make sure you've done everything you need to do. So you'll have changed your name. You'll have got evidence of employment. in your in your experience role yeah and all the other bits and pieces you need all the other bits and pieces you need to tick all the boxes you need to tick so that when your

gender identity clinic appointment comes up they say yeah good okay you've done all that okay we can refer you now okay so you may save a few may save a year or two at that end yeah but it's still you still got the weight they're still got yeah and a couple of the clinics are closed Yeah. You then see patients who are referred to you from the gender identity clinic? Yeah. So they would come after hormonal treatment. Is the idea that you would do hormonal treatment supported by surgery, or is it that you would do one or the other?

It's more of a stage. Okay. And not everybody goes to everything. Okay. I mean, there are some patients who go along to the gender identity clinic. Hormones are not for them, but they want to explore this different identity they have. and they don't feel they need hormones to do it there are some patients who take hormones they get changes they like it but actually they don't want surgery then there's the other

bunch who no that's that was lovely but I actually want the operation now yeah once you've had the operation do you continue on hormones yes forever yes yeah it's it's such a big thing I mean you know if you're looking at I mean if you have a trans woman in a 30, shall we say, and you say, well, you've had the operation, you don't need hormones. They get a menopause effectively. Yeah, okay, that's... So by the time they're 50, 60, they're going to be breaking bones and they'll be diabetic and depressed and all... Yeah, no, no, no, that's not very ever for the menopause either.

Thinking to another part of the sort of mainstream conversation that people are having the concerns that people have around this. guess, is that you might want to reverse it. People are scared that they're going to regret what they do. Does that happen? Do you see that happen? It does, but it's very, very rare. I think I've got one who, one patient who had the operation, woke up and recovered saying, oh my God, I've done the wrong thing.

But actually turns out she just didn't want the vagina I'd put in rather than was happy. And actually it's now, it's a strange arrangement. That patient now lives as a man with a female partner. Okay. But they are living as a male person. I had another patient who regretted it, had a phalloplasty done, and has now swung back the other way again. But this is out of 3,000 patients or so.

It's really rare. I mean, I think one of the psychiatrists in the London Clinic went through and I think was able to identify 40-odd patients. since the clinic was founded, who actually asked for a reversal. Which is given the number of thousands of patients that we've got. So it's pretty rare. And it is the quality of the assessment

and the psychiatry psychology, but it's the quality of that assessment that's important. How much research do you think is being done currently? Is it like a priority in, as the noise grows on the outside and you in turn see an increase in patients, are you seeing the sort of resources?

I kind of know the answer to that one, but are you seeing the research sort of matching the sort of noise? Research is a difficult one because in a perfect world, we'd all be busily sort of spending about a quarter of our time getting our data together and publishing stuff. But most of us are safely being busy, that takes a back seat. there are only a certain number of hours in the week

and if you're working clinically all the time you don't get much time to do the research there are people working hard but Amsterdam brilliant in terms of they've got it, they've got the money they employ research people to dig out the data and start again do the same

but here in Britain we're drowning why do you think that is is it a state of the NHS being in trouble anyway and we're just, or everything's overstretched? Well, you say everything's overstretched. Gender's worse by a factor of several more. Of course. The thing is, if you're looking to plan health service, health care, if you're looking at, shall we say, hip replacements,

you'll say we've got a slightly aging population. So we're going to expect perhaps 10% more hip replacements over the next four or five years. or whatever and we'll budget for that we'll make you know we can make some more clinics we can appoint some more surgeons a small number and so on so forth and things work out and you can keep on top of it gender's been doubling every five years yeah and something that roses rises that much they've got no no experience of trying to deal with that no so every time they put more money in we're going we're getting to the point where we should have been five to ten years ago but we've now moved on again.

Yeah. That's not to say that the NHS have been absolute stars. Perhaps I'd better not say too much. It's all very well making plans, but you've got to be a bit more agile, I think. Yeah. And actually sort of look at it and say, yeah, okay, this doubles every five years.

So the plan in five years' time is going to be double plus double. With it doubling as it is, I think I was reading about, I think it's probably the same, I mean, it will be the same in anything. I know in journalism you've got a code of ethics because if you write, if you ever report on a suicide, statistically as a result of you writing about that suicide, there will be, more people will die by suicide, having read that article. So there is always a sort of not cause and effect.

and there's always a sort of consequence to exposure. With the rise of the internet, it's meant that people have been able to connect with more people that look like them or feel like them or identify like they do. The increase in trans people is sort of rising as you'd expect given the exposure that they've got because people are finding...

I think in the last 10 years that's certainly true. Yeah. Prior to then, there was less exposure. less internet availability. I mean, there was some, but you know, you can, I'm sure, form a group on, I wouldn't want to say Facebook, because let's face it, that's so out of date these days. I don't think any of these conversations about your Facebook. Reddit's quite popular, I think.

Yeah. I think TikTok's big. TikTok's big at the moment. Yeah, people connecting with you each other than they say, who actually I feel the same and so on. It's good in some ways but bad in others. Well, I wanted to ask that where do you think the good is in that and where do you think the bad is within that? If you are in a situation where you're feeling pretty hopeless

and you've got something you don't completely understand, finding a couple of other people that are going through the same thing, helps, probably. The more dangerous side of it is I did see a forum once where somebody had published, these are the questions you will be asked when you go to the GIC and this is how to get through

to the other side to get your hormones. Okay. You don't really want that. No. You want people to answer for them the questions they're being asked. Of course, yeah, and you can get put on a path.

Yeah, you don't want people to be honest and if they're being encouraged effectively to say, well, this is what you'll be asked so you give these answers and you'll get your hormones at the end of it. It makes it more dangerous. To look more broadly at this whole conversation, I don't think I'm overstepping to say that Britain is quite transphobic.

Oh, everywhere's transphobic. Yes. It breaks down, largely speaking, on the grounds of religion across Europe. Okay. The Protestant countries have got established gender services. That's Britain, northern Germany, Belgium, Holland. They've got established gender services, been going on for a long time. The Catholic countries started getting underway in the late 80s, early 90s,

and we've got a much more sort of new and new services. Some aspects are but a good, some of them are less good. Okay. And then you've got the Eastern Orthodox who are just about getting moving. I think the first proper gender clinic in Greece was, it dates back, not much beyond 2000. Okay. And of course, the Russian Orthodox Church wouldn't allow it

and even if they did Putin wouldn't be that keen. No. No, I don't imagine so. With the UK, better than some, not as good as it could be, just the general rhetoric, what effect do you think that has on your patients, on on trans people I don't think they like being lumped into a bunch of

you know they don't like being regarded as perverts or sick because they don't think they are and they're right on this one I mean this is this is the worst thing about the well-known people who say trans women are doing it because they want to access

women's spaces so they can I'm not quite sure what they're going to do when they get there whether they're going to purve out on the women they see in the women's spaces or assault them or what I don't know and it's sort of labelling all trans women as being this sort of aggressive sex pest predatory person which they're not

no of course they're not I mean if you if you're a woman doesn't know but if if I'm not a lot of pest, but I don't know. But if I was of a mind to be a sex pest to assault women, I reckon it'd be a lot easier if I stayed dressed as a bloke. I think it would be a lot easier. And I think the data bucks you up on that. And I think you could probably do it and expect not to be caught or punished. So you're kind of fine on that. I'm not planning to start I don't get any further but I just that's um

that's one of the things where it all falls down you thinking why on earth would you do that yeah why would you wait four years just for your first appointment but even then you know dressing up in a dressing up

in women's clothing just so you can excise what actually are these women's spaces and they never tell me no I heard people talk a lot about public bathrooms well there is no such

thing as a women's toilet and a men's toilet. Is there not? No. Oh my God. What is it? That's convention and we bow to it, that we do separate ourselves. But actually, there are two laws, there are only two points of law about toilets. Number one, you should use one. That seems a good law to me. Okay, yeah. Yeah, you know, crapping in the street, it leads to sort of public health nuisance and all the rest of it. Yeah. And number two, unless you are disabled, you should not use the disabled toilet.

And those are the only two laws. Yeah. That gets largely omitted from this conversation. Funnly that, funny that, isn't it? But that's just, that's because people assume, there's a lot of things that people assume are the case and there must be covered by law. But segregated toilets is not actually specified by law.

It's conventional and I think on the whole most of us feel more, I can't think of any worse than going into a women's toilet, to be honest. I can't think of much worse than going into a men's. I remember going in age seven with my dad once in Hamleys, and it was absolutely traumatising. But, I mean, you know, I can remember years and years ago when I went skiing in Switzerland at the same time I've ever really been skiing. And there was a big mixed toilet.

And it didn't feel particularly odd. No. And there probably wasn't outcries and opinion pieces being written. And there wasn't a huge cue of women waiting for their bit while the men were sort of breezing in and out. interesting that the British Airways lounges at Heathrow have gone unisex now that's interesting previously there used to be two sort of blocks all cubicles

one said men and the other said women and now they've just said toilets okay which I mean actually it's probably pretty sensible it's incredibly sensible I'm always fascinated by the fact we get hung up on And I feel like I'd be remiss not to ask you. The other thing, I was loathed when I was writing these questions. I don't want, we didn't want to just hit all the like. There are a few buzzwords with this conversation.

There are a few things that you know are going to frustrate people and you know that people are going to get their knickers in a twist about public bathrooms, which as we've just discussed as nuts. But the other thing people get the knickers and a twist about a sport. There's more, that's slightly more difficult. Well, this is it. It is more difficult. but it's two very specific things

that actually by and large are not affecting most people. Sport. I played cricket this morning, but I don't know if you were told or not, but I did. I actually, I was. I heard, yeah.

That's good. Pretty poor quality cricket. Okay. But I enjoy it, and a bunch of people I was playing with seem to enjoy it as well. So I think participation in sport is good for people.

Whatever sport it is. I might be riding a bicycle, it might be running it, it might be playing team sports, but I think it's basically good for you. The problem really, I mean, if you're playing amateur sport and you're a sort of 14 and a half stone prop forward

who suddenly transitions, you're probably not playing well enough to beat the really good women anyway. So you can probably find a slot where you can fit in where you're accepted as what you do, the problem gets when it gets to elite sport and you've got lots of money involved.

And the sort of money of an Olympic gold medal winner can expect is significant. I'm not saying they're not worth it. I'm just saying it. And I do get that the sort of bigger levers, more muscle mass of the trans woman gives them a significant advantage.

But I don't think it really matters when it's down at amateur level because they're playing for the women's first rugby team or the women's first soccer team whereas other people aren't getting into that. But the other people don't mind because they're still playing. It's the elite level of sport

where there's a lot of money involved. And I do get that, you know, as a professional, I've never been a professional sportsman. But I mean, if you play sport as a profession and someone comes in who's got these apparent advantages, you might feel decidedly miffed that your earnings potential have been, you know, I can't win the gold medal

because that person's running. And there's this group of women who have disorders of sexual differentiation, isn't it, called DSD? typically who produce a lot of testosterone who wipe the floor with their with other women when their testosterone's not suppressed and also runs when they

when it is it's difficult you end up in the sort of the argument about Castasamania if you look at her before her testosterone took off she was an also ran. Yeah. She then worked the floor with the entire field. She was then told you have to suppress your testosterone,

and she became an also run again. It does feel case. I think the point with that is that we are oversimplifying this conversation based on some very unique, quite often hypothetical situations. Yeah. But I mean, the things like the swimmers. Yeah. I mean, if you've got great big long arms and huge feet,

you've usually managed to swim faster. Yeah. That's an advantage which you were given just by different. And if you started life as a bloke, you've usually got bigger feet and longer arms. Yeah, it's an advantage. So you've got an advantage there, which doesn't matter if all you're doing is bashing up and down the pool and appearing in amateur regattas. I don't know what we call it. I've temporarily forgotten the word for the swimming thing.

Swimming gala. A gala? Yeah. Not regattas. That's boating. Yeah, I know these are not my sports. You could have said anything. I wouldn't have.

I can't, I don't have my head under the water. So this is not my area. Swimming's not my idea of fun, actually. But, yeah, I get, but I think it is the elite level of sport where it becomes important. Which is not a sort of typical situation for most of people in your clinic, most trans people in the UK are not. They're not supreme athletes. No, they haven't got Olympic hopes. And, you know, they can participate in sport

and they might be a slightly small bloke, a trans man who enjoys playing cricket. Yeah. Or a largeish trans woman who's quite good and plays for the better teams in her club at rugby or tennis or whatever. But it's participation. There's no money involved, and it doesn't matter that much.

No. But I said, it is frustrating that the whole conversation, which is huge and broad and complicated and serious, is being sort of whettled down to these two sort of buzz issues. I mean, I used to ride a bicycle on a regular basis, and I went out with a club, and I got my backside kicked very seriously by a couple of the women because they were so much faster than me. Yeah. Oh, I think my mum would probably do that. My mom's an absolute tank on the bike. Yeah. And would I mind, no.

No. I'd try to get beaten a little less next time. We will let you go before I do. I just, this is a bigger question and I don't know. I don't really know what the answer is for it. But the government, as they are now, are trying to, they're making a lot of decisions or they're having a lot of conversations about what the right thing to do is here.

I don't know, because I don't know anything about medicine, honestly. I don't know how much government is involved generally with treatments, with these conversations as standard. Is it unusual for the government to be so involved with the treatment of an illness or of a condition? Well, no. You remember Big Dave Cameron and his. cancer fund.

Yeah, okay. He did suddenly announce that because of political pressures, he was going to put extra, extra money into cancer. I mean, Nice are already allowed to spend 10 times as much on a cancer drug as they can on an ordinary drug. Wow, that's interesting. And Big Dave decided he was going to have an extra cancer fund for people who needed drugs that weren't even accepted by Nice on that basis.

So it's not that unusual. Okay. things get kicked around cancer is always very high profile yeah and you tend to find more political interference in that than you might in in other areas okay gender it's got a relatively high profile has had for about 10 years now yeah do you see it going anywhere that profile I'm rather hoping it doesn't you think do you think on balance it's a good thing I do that's good I mean, I think if gender just disappeared into the background, if people stopped thinking about it, stopped acknowledging it,

it would be worse for the patient group than it is now. So on balance, the debate and the pushback and the concerns and that sort of thing is in a way enabling a conversation that is probably, on balance, supporting, or at least progressing. It's like the no publicity is bad publicity. It's the same as that. If you're not being talked about at all, people aren't going to notice if things get shut down.

That's very true. You could find that somebody announces in the Department of Health that we're going to stop doing gender surgery because they don't think it's right. they wouldn't be able to get away with it at the moment because we're right up there gender's visible the only just talks about

they might be able to get away with it I don't know I shouldn't try my luck on that one no careful but if you see what I mean I think and I think because it also demonstrates the community that they're not alone

as we've talked As I talked before, that, you know, that they now out there, there are other people going through the same misery. And it is, I think it is misery, actually. I think my patients have a pretty miserable time as they transition. Yeah. And they're usually happier after surgery, usually. Usually a lot happier after surgery.

But it's not panacea. It's not sort of, I've had surgery, life is now brilliant. Yeah. They've still got a lot of work to do. Yeah. They are usually happier, but they've still got a lifetime of putting up with a bit of prejudice and, you know, people moving to sit on the other side of the train carriage because after all, you know, it's infectious, isn't it? Notice I've caught it over the last 25 years. I think that's a really good point to her end on.

This has been such a good conversation. so much for coming and having it with us. It's tragic. She's not here. I'd sack her. She's gone. She's gone. Yeah, I'd get rid of her.

I'd get rid of her. So next time she comes along, she put a parcel on the door and it just went open. No, I like that. I like that you think we've got passes on the door. That's a good esther. Well, no, I was given a key fob to get back in. Oh, my God, we do have a... Yeah, you see?

We've got... Right, yeah. So, yeah, you can disable her key fobs. You can't at the door and... Yeah, that's exactly no less than she deserves. This has been really great. Thank you so, so much for talking to us. Take care.

Thank you. Should I delete that as part of the ACAS creator network?