The problem, according to Phil Thomas, is this: there are simply not enough people in Britain who know how to make a vagina.

“We need more surgeons,” the urologist said from the private Nuffield hospital in Brighton. “In March I received 24 new referral letters. Multiply that by 12 and you can see what the issue is.

“The volume that we need to do to meet the demand is just going through the roof and NHS England are not keeping up.”

The problem of waiting lists for transgender patients who want genital gender reassignment surgery (GRS) is not just one of growing demand, but of supply. This is niche work. Thomas is one of fewer than a dozen practitioners in the UK. About two-thirds deal with male-to-female surgery – vaginoplasty – and the other third handle the opposite procedure – phalloplasty for trans men.

If we [surgeons] were both on a plane … and something were to happen, there’d be a problem Phil Thomas, urologist

Most work both privately and on the NHS. One has just gone on maternity leave. Thomas and another colleague, James Bellringer, are due to retire in the next five years. “At this stage if we were both on a plane to go to a meeting abroad and something were to happen, there’d be a problem,” said Thomas.

Thomas calculates that people wait about six months for his services. For Bellringer, waiting times are even longer. His NHS patients in London face waits of more than a year and a half.



Referrals for vaginoplasty surgery have been growing at 20% per year and as of March 2016, 266 trans women were waiting for surgery at Charing Cross, the oldest gender identity clinic in the country.

“One of my patients has been making ‘Bellringer Babe’ badges,” he said with a smile. The badges bear the silhouette of an elegant woman in a ballgown and indicate that the wearer has had male to female gender reassignment surgery (GRS) at the hands of the London-based surgeon.

Bellringer came to vaginoplasty almost by accident, in 2000. He was working at Charing Cross hospital in west London, part of Imperial College NHS trust and the only NHS hospital that performs the surgery in the UK, when Mike Royle, the surgeon who built up the practice for GRS in the UK, announced his retirement.

“I was in the right place at the right time,” said Bellringer. “They needed someone with the technical ability and the right approach with the patients, so they asked me.”

In 2014 Bellringer and Thomas were joined by Tina Rashid, a 34-year-old urologist who is now the only woman performing gender reassignment surgery in the country. “There are not many younger surgeons going into gender reassignment,” said Bellringer. “Tina is our secret weapon. She is down there with the kids.”

James Bellringer, who performs male to female gender reassignment surgery. Photograph: Alicia Canter/The Guardian

Rashid first witnessed vaginoplasty surgery during her training period at Charing Cross, where she was appointed as consultant in 2014. “I knew it would be a missed opportunity not to observe the surgery,” said Rashid. “Wherever I ended up, at some point in my consultant career I would see a handful of patients who had male to female reconstruction. I wanted to understand how to treat them.”

“James and Phil should really be credited for setting up the service in the UK,” she continued. “I see my role as really helping take it forward. They are towards the end of their careers and I am at the beginning of mine.”

But attracting new surgeons into the speciality was, said Rashid, “extremely difficult”. “GRS is a very niche area. A lot of trainees don’t get exposure to it,” she said.

The situation is not likely to improve in the short term. Rashid went on maternity leave in April and expects to be away for the rest of the year. Charing Cross has been training a new surgeon to replace her, but he is not quite ready to operate. There are two others doing a small amount of this work for the NHS elsewhere in the UK, Oliver Fenton and Charles Coker.

In contrast trans men looking to have female to male reassignment surgery are in a better position – those who wish to have genital surgery can expect to receive it within the 18-week referral target.

Estimates from the Charing Cross gender identity clinic suggest that whereas about 60% of all trans women will go on to have genital surgery, only 10-30% of trans men will want phalloplasty – the surgical construction of a penis, which involves four operations and takes a total of 16 hours.

David Ralph, consultant urologist at St Peter’s Andrology Centre in London, and his team treat about four trans patients a week and receive 200 new patients a year.

“There are a lot more male to female trans patients than there are female to male, but saying that it takes four operations to make a penis and only one to make a vagina,” said Ralph. “The main thing that trans men want is to be able to stand to void [urinate]. Secondary to that of course is being able to have sex with their new penis. This really changes their lives.”

The surgeons performing these operations are passionate about what they do and urge more of their colleagues to consider training to be able to do the surgery.

“I think most of my urology peers think I’m mad. Well actually, compared to staring down a laparoscope for four hours removing someone’s prostate this is much more fun,” said Bellringer.

For Rashid, the driving force is being able to help a group of vulnerable patients who are at high risk of depression, anxiety and suicide.

“I have patients say: ‘You have saved my life.’ It is very gratifying and not something that I can quite put into words,” she said.