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0:30

Welcome to The Referral.

0:32

I'm Dr. Karan, a surgeon in the UK. And if you

0:34

like to learn simple strategies to

0:37

improve your health without the pseudoscience,

0:40

you're in the right place. Every week, I'm gonna be joined

0:42

by experts and interesting people,

0:44

and we're gonna give you actionable take-homes that

0:47

you

0:47

can apply to everyday life. Today's

0:49

episode is fascinating. I'm

0:51

gonna be diving deep into the world of

0:54

gender surgery. And to that

0:56

end, I'm gonna be joined by one of the most

0:58

famous doctors in the world, and

1:01

one of the very first gender surgeons

1:03

in the UK, James Bellringer. In

1:06

terms of the specific risk of surgery,

1:08

what worries me most every time I think, every

1:10

time I start doing an operation, I worry about it, is

1:13

making a

1:14

hole in the rectum. What is gender surgery? Well, it's

1:16

a type of surgery that permanently alters a

1:20

person's body part associated with their biological sex.

1:22

In simple terms, gender surgery involves

1:24

things like creating a new vagina, a

1:27

vaginoplasty, removing a person's testicles,

1:30

an orchidectomy, removing penises, a penectomy,

1:33

and way more. And if you've got a question

1:35

for me

1:36

to answer, head over to thereferralpod.com and get in touch. Excitingly,

1:40

today, you're gonna have another brand new shiny

1:42

episode of Crowd Science Extra. This

1:45

episode will be dedicated to all things health, science,

1:48

and medicine. So feel free to get in

1:51

touch at thereferralpod.com and ask

1:53

your questions. And a bit later,

1:56

we have,

1:59

debunk all of those silly myths that you

2:02

hear online or in the real world. But

2:04

first, it's what the health. What

2:06

the health is going on in the world of medicine,

2:09

science and health.

2:14

So it turns out your number twos could

2:17

be the number one defense against liver

2:19

disease. Now I'm not suggesting

2:21

you start munching on your feces

2:23

to improve your liver, although some

2:26

pseudoscientists may eventually start

2:28

to proclaim that and you definitely should run away from

2:30

them. But there is a new trial

2:32

that's going to be started by King's College London

2:35

to investigate fecal microbiota

2:37

transplants, poo transplants, poo

2:40

pills or crapsules to help

2:42

patients with liver disease, specifically

2:44

liver cirrhosis. Now if you're interested

2:46

in learning a lot more about poo transplants

2:49

and your microbiome, go and catch

2:51

the episode I did with Dr. Blair Merrick

2:53

and we go into the nitty gritty of

2:55

poo pills and that is fascinating. But

2:58

in this study, what they're proposing

3:00

is that they could take good bacteria in the

3:02

form of fecal microbiota transplants and

3:05

give them to patients with advanced

3:07

liver disease and liver cirrhosis because it's

3:09

thought that patients with liver cirrhosis

3:12

have dysbiosis, a increased

3:15

amount of bad bacteria and a scarcity

3:18

of good bacteria. So if we can transplant

3:21

good bacteria in these poo pills

3:23

into these liver patients, we can improve

3:25

their gut microbiome and reduce their

3:28

risk of infection because if a patient

3:30

with liver disease or advanced liver cirrhosis

3:33

gets an infection, it could potentially be fatal.

3:36

And a lot of patients with liver cirrhosis, they

3:38

often end up on different courses

3:41

and recurrent courses of antibiotics

3:43

and they develop antimicrobial

3:45

resistance. And one of the unfortunate

3:47

things with liver cirrhosis is that a patient,

3:50

if they're infected with a bug that is

3:52

resistant to any antimicrobials,

3:54

then they would no longer be a candidate for a

3:56

liver transplant, which is the only curative strategy

3:59

we have right now. for liver cirrhosis.

4:01

So they've established the feasibility and

4:04

safety of doing these poo transplants

4:06

for liver cirrhosis patients in a very small

4:08

study of just 32 patients in a European

4:10

study. And they're hopefully going to replicate

4:12

that in much bigger numbers in

4:15

the King's College London study. And

4:17

who knows, and you might think liver

4:19

disease and liver cirrhosis, it's quite rare, but in

4:21

the UK, it's the third most common

4:23

cause of death.

4:26

And that is your weekly dose of science news.

4:29

But now for something even more interesting,

4:32

my conversation with gender surgeon,

4:34

James Bellringer.

4:37

So as a busy surgeon trying to balance

4:39

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5:37

Why were medieval priests

5:39

so worried that women were going to seduce men

5:42

with fish that they'd kept in their pants? Who

5:44

was the first gay activist?

5:47

And what on earth does the expression sneezing

5:49

in the cabbage mean? I'll tell you,

5:51

it's not a cookery technique, that's for sure.

5:54

Join me, Kate Lister, on Betwixt the

5:56

Sheets, the history of sex scandal in society,

5:58

a podcast where we... be bed hopping throughout

6:01

time and civilization to

6:03

bring you the quirkiest and kinkiest stories

6:06

from history. What more could you possibly

6:08

want? Listen to Betwixt the Sheet today

6:10

wherever it is that you get your podcasts. A

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podcast by

6:13

History Hit.

6:17

Thank you

6:19

so much for joining me. I know a lot about you

6:21

because I was a medical student

6:24

when you were doing your gender

6:26

surgery in Charing Crow Hospital but

6:28

for those listening at home who

6:30

are you and what do you do?

6:32

I'm James Bowringer. I trained

6:34

as a general urologist but I moved

6:37

into gender surgery specifically

6:41

feminizing genitalplasty

6:43

which is starting with male

6:45

anatomy creating something that as closely

6:47

as possible resembles female anatomy from a genital

6:50

point of view. So you offer gender

6:52

surgery

6:53

for those people with gender dysphoria

6:56

who are female but are genotypically

6:59

male. Genotypically

7:01

male and who want to become phenotypically

7:04

female.

7:05

They wish to resemble female as far

7:07

as possible. What do you define as

7:09

gender dysphoria? What does it mean to you? It's

7:12

a deep unmovable sensation

7:14

that your external appearance

7:17

does not conform with what's

7:19

inside your head.

7:20

Okay and how prevalent do you think

7:22

that is? The

7:24

world not just the UK and just general population

7:27

the incidence of something like that? I mean if you look at incidents

7:29

across the world it's pretty much the same everywhere. There's

7:32

cases of under-reporting where you've got

7:35

repressive regimes. I mean gender

7:37

dysphoria is apparently quite uncommon

7:39

in Russia. It's

7:42

quite uncommon in some

7:44

other countries where you might expect

7:46

it to be. Interestingly it's

7:49

above average in Iran but there's

7:51

other reasons for that. Why is that? Is that because from a cultural

7:53

point of view they're more accepting of a third

7:56

agenda or? No no Iran has

7:58

got its own problems.

7:59

In Iran if you're a gay

8:02

man and you get caught

8:04

with another man you both get stoned to death,

8:06

right? I think that's

8:08

the rules But

8:12

the Ayatollah said that

8:15

Changing gender was acceptable. Okay,

8:17

and so a number of people actually say well, it's you know,

8:20

I'm not gay. I'm gendered dysphoric I I'm

8:23

a really a woman

8:24

So it's there's

8:26

a slight artificial increase there. So there are

8:28

a few fluctuations, but Globally,

8:31

we think probably one in sixty

8:33

thousand one in a hundred thousand people.

8:35

Okay, so it's rare It's it's rare But

8:37

you know on a you know The law very

8:40

large numbers if you take you know millions and millions

8:42

of people that

8:43

accounts to a significant number of people

8:45

Yeah, you are gender dysphoric. Yeah and

8:47

surgeons around the world are all completely

8:50

Absolutely snowed under surgery for

8:52

people who suffer with gender dysphoria, you

8:54

know, it's been going on you could say since the 1930s

8:58

Or more in the 60s in the UK, but in the world the

9:00

1930s in German Well the the

9:02

German case yes, and about that we're down to 32 90

9:06

Yeah, I mean that that was feminizing

9:08

surgery. There's no vagina

9:10

no vagina So that was removal of

9:13

males in a creation of a vulva

9:15

From male genitalia

9:17

that was probably the first recorded case.

9:19

Dr. Hershink in Berlin

9:22

in Berlin, but a lot of the Anatomy

9:25

and the medical records from that period of time

9:27

were destroyed by the Nazis Do

9:30

you think just hypothesizing

9:32

and you know thinking about the techniques

9:35

of surgery they used back then? How wildly

9:37

different would they have been to some of the

9:39

things you're doing now?

9:40

I think from the external point of view

9:43

quite a lot of similarities I'm fairly

9:45

certain they weren't creating a vagina. So that's a

9:47

whole step onwards and I

9:50

think the first recorded vagina plasti

9:53

is probably in Britain. So probably

9:55

around 1950-51 The operation

9:57

would have been done. So

9:58

when

15:59

but actually professionally I'd always had an

16:02

interest in sexual medicine.

16:03

Someone's not going to just rock up at your door at

16:05

your clinic or in the hospital and have feminizing

16:08

surgery the same day. What is the process

16:11

that someone has to go through until they

16:13

have surgery? There's a long lead time of psychological

16:16

evaluation and real life experience. What does

16:18

all that involve? Real life experience is gone by

16:20

the way. That went and that went. Do you think

16:22

it's good or bad that

16:24

they've removed real life experience

16:26

when someone is about to remove the term?

16:28

They've removed the term. They've removed the term

16:31

because it's a load of mumbo jumbo

16:33

real life

16:33

experience. What's

16:35

that mean? We

16:39

talk more now about social transition. Social

16:41

transition. You have somebody

16:44

who

16:45

goes into their new social

16:47

role in the gender they experience.

16:50

If it was you, you'd

16:53

have to have a shave to start with.

16:55

So would I. Do

16:57

you? Does

17:00

one need to shave?

17:03

I think making out that you're

17:06

doing the full female role if you've got a full

17:09

face of hair is difficult

17:12

to say. You could be gender

17:14

non-conforming, you could be non-binary. Say

17:17

you're female with a full beard. Yeah.

17:24

The social transition phase now, how

17:26

long does that have to last before gender

17:28

surgery?

17:29

A minimum of a year. That hasn't changed.

17:31

And what follow-up or contact

17:34

do you have with these patients in that year? I

17:36

don't see them. You don't see them at all? I don't see them before

17:38

they've completed that usually. But you see them at

17:40

the start and say they need

17:42

to go into the social transition? No, I mean,

17:45

I will occasionally have somebody who

17:47

books themselves into my private clinic

17:49

and says,

17:50

hello, I want an operation,

17:52

please. And I say, well, where are you in terms

17:55

of transitioning? Has anybody seen

17:57

you who's a

17:58

gender specialist?

19:54

and

20:01

get to the point where they're actually content

20:03

to carry on as they are. Without any

20:05

surgical interventions. Without surgical, without hormones,

20:07

with nothing. OK. And

20:10

there'll be other people who cannot

20:12

cope unless they go right along and have

20:14

an operation. And it

20:16

doesn't make them less gender

20:18

dysphoric at the beginning, it just means that

20:21

what's required to make them... It

20:23

stratifies the intensity of their management,

20:26

that social transition phase. Yeah, I mean,

20:29

the important thing about the social transition and

20:31

the hormone environment, of course, is if

20:33

you're going to come to see me and have a vagina

20:36

plasty, I'm going to remove both your testicles.

20:38

Yeah.

20:39

So you're going to be... Which is irreversible.

20:42

Pretty much, yeah. I mean, you

20:44

know, so you're going to have no testosterone. Yeah.

20:47

And unless you've experienced that before I've done it, it's...

20:50

And if, you know, if you find actually that having no testosterone

20:53

is a bit of a bad thing, you

20:55

know, and,

20:57

you know, it's just imagine going through it without the

21:00

social transition, without hormone treatment.

21:03

So one day you turn up

21:05

and you shave your beard off

21:08

while you're in hospital, and the next day you go out, no

21:10

testosterone wearing a dress

21:13

and with the vagina. It's not going

21:15

to work. I mean, for a lot of people, that's going to be a disaster.

21:18

If you remove someone's testicles and orchidectomy,

21:21

and you remove their factory of testosterone,

21:24

we know testosterone is for more than just

21:26

muscle mass, but for bone health, mental health

21:28

and various other things. How do you

21:31

account for the steep drop

21:33

off of testosterone and the insidious effects

21:36

of the sudden depletion of testosterone?

21:38

Well, they're all taking hormones anyway. So their

21:41

testosterone level is reduced to zero

21:43

or close to zero, either

21:45

by the use of GNO,

21:48

RH analogues,

21:51

to start with, or if you give enough estrogen, it'll do it

21:53

anyway. So

21:55

they have, they move to

21:57

a female hormone environment.

21:59

And because they've got Eastern on board,

22:02

the mental health, diabetes, osteoporosis,

22:04

and so on and so forth. It's mitigated by the

22:06

Eastern. It's not mitigated, it's eliminated. If they're

22:09

on appropriate Eastern levels, they will not

22:11

get all those problems. And

22:14

this is still a major surgery

22:16

that someone has to undergo. What are some

22:19

common risks that you see and

22:21

catastrophic risks with this type of surgery that

22:23

you've seen?

22:24

I've unfortunately had one death in my

22:26

career so far. It was a patient

22:29

who died from a pulmonary embolus, which

22:31

for the non-medical listener is where

22:33

a clot forms in the legs during

22:36

the

22:36

perioperative period. And a bit

22:38

of that clot breaks off and it blocks the

22:40

main artery to the lungs. And

22:43

that pretty much stops the heart with the effect

22:45

of instant death. It's

22:48

fortunately a rare complication, perhaps

22:50

one in 2000 in major

22:53

surgery, but we do our best to eliminate

22:55

it, but you can't eliminate it completely.

22:57

In terms of the specific risk of surgery,

22:59

what worries me most every time I think, every

23:02

time I start doing an operation, I worry about it,

23:04

is making a hole in the rectum. The

23:07

rectum and the prostate are

23:09

less than a millimeter apart in terms of- Fearing

23:11

the same wall.

23:12

There's a nice layer of fascia between the two

23:15

and you've got to get in the right side of that and then you're safe.

23:18

But

23:19

every time you think you've cracked it and

23:22

you've, you'll never, I know exactly how to

23:24

do this now, I'll never make another hole in the rectum. And

23:27

then all of a sudden one day you do. And

23:30

most of the time you repair it and it's fine and

23:32

the patient recovers and doesn't have a problem and so

23:34

on. But if you get a fistula, it's a major

23:37

nightmare. Oh, it's a lifelong potentially- Well,

23:40

it's potentially a lifelong

23:42

colostomy. Fortunately,

23:45

most times it doesn't. Now, I'm

23:47

sure a lot of patients, once they undergo

23:50

gender surgery, they feel great and

23:52

you probably get plaudits from them yearly.

23:55

But do you see a significant

23:57

percentage or any patients coming in with-

25:59

feasible at all in any

26:02

way in terms of plugging it into

26:04

the existing blood vessels that's there in

26:06

a non-gynecoid pelvis.

26:09

Right. Okay. Utrone transplant has

26:11

been done,

26:12

but not into trans

26:15

women, but uterine transplant

26:17

into... Female to female. Sys

26:19

women has been done, and

26:23

there have been live births from the

26:26

donated uterus. It can

26:28

be things like

26:30

the mother

26:31

gives her uterus to the daughter who

26:34

lost hers in some disaster, some

26:36

accident, some whatever. Some tragedy, yeah. It's

26:39

not a very common thing. I mean, most

26:41

women between the ages of 16 and 50,

26:44

the

26:46

vast majority of them hang on to their uteruses nowadays.

26:49

But the uterus is usually removed

26:51

after birth of the baby? They usually

26:54

remove the uterus at the same time. So they can then stop

26:56

the immunosuppressive medication. Yeah.

26:59

So in this surgeon who wants to pioneer

27:01

this in a male anatomical

27:03

pelvis? Absolutely no reason why they

27:06

shouldn't put a uterus into a man

27:08

physically, technically, as possible. Really?

27:11

It can be done.

27:13

And there's no issue with... But the

27:15

issues I think, I think the issues are

27:17

largely ethical. I mean, with regards

27:20

to the sort of ethical conundrum of what we've

27:22

just spoken about, in light

27:24

of the Olympics next year in Paris,

27:27

and the increasing amount of

27:29

transgender women competing in the

27:32

female category in sports, I

27:34

know the International Olympic Committee had

27:37

certain designated criteria in terms of

27:39

how much testosterone would be appropriate.

27:41

So trans women in

27:43

female categories, they would have

27:45

to have at least a less than 10 nanomoles

27:48

per litre of testosterone. That's

27:50

quite a lot. That's still quite a lot. And above

27:53

the female range of testosterone.

27:55

Exactly. And the role

27:57

of testosterone prenatally, so in the...

27:59

womb and pre-pubertal

28:02

testosterone and during puberty, that

28:05

exposure to early life testosterone has

28:07

lifelong positive benefits

28:09

in terms of muscle mass, bone density. Yeah,

28:12

the trans women don't see them as positive benefits. Those

28:14

are positive benefits, but in terms of a physiological

28:17

change, those are lifelong. It's giving you

28:19

a potential athletic advantage, taller,

28:22

bigger bones, bigger levers.

28:24

It becomes difficult when

28:26

you're talking the sort of megabucks that top

28:28

sportsmen can get, because

28:31

then reasonably,

28:34

if you're coming up against somebody who,

28:36

for example, has been a triathlete as a

28:38

man, who then transitions,

28:41

is now a trans woman who is breaking

28:43

world records.

28:44

Yeah. For the fact, I don't think any of them

28:48

have. It means that competitive women's

28:50

sport is difficult. Yeah.

28:54

I don't know the answer. I

28:57

mean, a few sports are gradually

28:59

stumbling towards the,

29:02

well, we'll have an open category. Because

29:04

a lot of elite level female athletes have

29:06

spoken out against trans women

29:09

in the female categories. I

29:11

think that's reasonable. I think I can understand completely

29:13

why they would do so, because at

29:16

their elite level, they're making their money out of

29:18

competing at sport. Some

29:20

of the myths around feminizing surgery

29:23

and just

29:24

gender surgery in general that I've

29:27

seen in the news outlets and a lot of people

29:31

online comment that a

29:33

lot of it is psychological, which

29:35

it's clearly not. But

29:37

in terms of the psychology

29:40

of wanting feminizing surgery and

29:43

gender dysphoria in general, how much of

29:45

a psychological component is there?

29:49

Psychological suggests

29:51

that it might respond to treatment, if

29:53

you see what I mean. Exactly. Which is why

29:55

so many people saying. This is the way your

29:58

brain is built. Yeah.

29:59

same as people being left-handed. And

30:03

I've got a friend to South Africa, and he can remember at

30:05

school,

30:06

the left-handed

30:09

kids had their left hands tied behind their backs,

30:12

because they were not allowed to use their left hand to write

30:14

with. Even more recently, as a

30:17

junior surgical doctor years ago, when I started

30:19

on orthopedics, I was banned

30:21

from using my left hand. I had to only operate

30:24

and stitch with my right hand, I was told. Yeah.

30:28

And it's

30:30

about as stupid as that. If you've got somebody

30:32

who's left-handed, nowadays,

30:35

nobody would dream of saying, you must write

30:37

with your right hand. Put your left hand, you know, and-

30:40

It's the way your brain is wired. That's the way your brain

30:42

is wired. Interestingly, if

30:44

you're looking left-hand, right-hand, there's a

30:46

higher proportion of left-handers who are trans

30:48

than right-handers. Really?

30:50

There are more right-handers who are trans, but a

30:53

proportion of, yeah. Do you think

30:55

in the UK specifically, we

30:57

are ahead of the curve or behind the curve

30:59

when it comes to progress in

31:02

gender surgery compared to other countries?

31:06

We've got more mature gender services than

31:08

in a lot of countries. Yeah. And

31:10

interesting, that's religious as well. Yeah,

31:13

okay. If

31:15

you go across Europe and

31:17

Asia, you can pretty much predict

31:20

what sort of gender service you're gonna have

31:22

based on the religion.

31:23

So the Protestant

31:27

countries, Belgium, Northern

31:30

Germany, Holland, us, you

31:34

can predict we'll have established gender services

31:37

going back to the 50s, 60s. The

31:40

Catholic countries, typically

31:42

it starts around 80s, 90s, far

31:45

less mature services. And

31:47

Greek Orthodox, Russian Orthodox,

31:50

only really just got going in the 2000s. Wow,

31:54

it's all down the curve. Yeah, a long way

31:56

behind. So James, before I let

31:58

you leave, I know you're a busy man.

31:59

And you have a question for me. I don't know what it

32:02

is, so shoot. Right,

32:04

okay, you're a general surgery, I think. Yeah, general

32:06

surgery. You're gonna come and join me? What

32:09

about coming and doing gender surgery? I would

32:11

love to be involved and see

32:13

you and assist you. I mean, I have not done

32:15

urology for a number of years now. You don't have to do

32:17

urology.

32:18

You don't have to do urology. As a general surgeon,

32:20

you could do gender. Really? You

32:23

could come and do vagina plasties.

32:24

But I've never operated on that

32:27

before.

32:28

I've been doing bowel cancer operations,

32:31

gallbladder operations. Well, if you can do

32:33

a laparoscopic anterior section, you'd be

32:35

very useful doing the peritoneal vaginas.

32:38

Interesting, wow.

32:39

And we need people

32:41

who are interested in thesiastic and capable.

32:44

I suppose the capable's the most important bit, but yeah.

32:46

So what is the training pathway

32:49

after someone finishes their surgical

32:51

training in general surgery, as I will do, in

32:53

probably 18 months to two years?

32:56

At the moment, we've got some fellowships

32:59

in gender surgery,

33:00

and you'd come and go for one of

33:02

those for about a year, and then you'd be

33:05

trained to do gender surgery.

33:07

Wow, incredible. That is incredible.

33:10

That is something to consider. Yeah. I think

33:12

we'll have to have a chat off air. And anybody else who's listening

33:14

to the podcast who's a surgical trainee who,

33:17

you've got to be doing urology, plastics,

33:20

general surgery, or gynecology to do

33:22

genital surgery. But if you're doing any

33:24

of those things, and

33:26

fancy doing something really quite

33:28

exciting, and

33:30

I wouldn't say niche, but really quite exciting,

33:32

and actually extremely worthwhile, come

33:35

and see me. Yeah, absolutely. Thank you. Thank

33:37

you so much for taking time out to come and have a chat

33:39

to me, James. Pleasure.

33:41

I want to tell you about a little secret of

33:43

mine.

33:49

It's called The Secret Mum Club, and it's a brand new

33:51

podcast that's all about the little secrets that

33:54

we keep to ourselves as parents to get us through

33:56

the day. Whether it's questionable parenting

33:58

techniques, hilarious fails,

33:59

cringe-worthy moments of madness from your little

34:02

ones, the easiest thing to do for all concerned

34:04

is to brush it under the lightly-soiled carpet

34:07

and pretend everything is okay. So

34:09

join me, Safeena, and my secret sidekick

34:12

and mom friend, Emma Jones. Hiya. Just

34:14

search and follow The Secret Mom Club wherever you get

34:16

your podcasts.

34:20

Hey, I'm Josh Peck. And I'm Ben Soffer.

34:23

And we're the Good Guys. On our show,

34:25

every week we talk about buzzy pop culture

34:27

stories. Maybe answer a couple of your voicemails

34:31

and go into a moment of the week that makes you say,

34:33

what are you, nuts? And I swear, it's so much

34:35

better than this promo. Anyway,

34:37

there's a lot of guys out there, but we're

34:39

the Good Ones. Stream Good Guys every

34:42

Monday wherever you get your podcasts.

34:44

Apple, Spotify, anywhere. You

34:47

know what? Don't listen.

34:53

Thanks to James Bellringer for that really

34:55

enlightening conversation. And the

34:58

vocabulary and our understanding

35:00

of gender surgery is constantly evolving.

35:03

So as someone who treats

35:06

men, women, transgender patients

35:08

as well, it's important to be up to

35:11

date and up to scratch with not

35:13

only terminology, but also advances

35:15

in science, medicine, and surgery.

35:22

Okay, it's now time for If It Ducks

35:24

Like A Quack. And I've seen

35:27

so much nonsense online and I've recently

35:29

been forward by dozens of you, this

35:31

specific video about someone talking

35:33

about mouthwash and how mouthwash

35:36

is incredibly dangerous for your oral health.

35:39

Is that true? Is that a myth? Well, as

35:42

always, it's not a black and white picture

35:44

and there is some nuance and I wanna give you the science.

35:47

So as with most places in your body,

35:50

your mouth, your oral cavity

35:52

is also home to various bugs

35:55

and microbes. And it has its

35:57

own little ecosystem inside your mouth, the oral

35:59

micro- microbiome and just like the microbiome

36:01

in your gut, in your skin, everywhere else, you

36:04

need to take care of this delicate

36:06

tropical rainforest of microbes inside

36:08

there as well, which includes flossing,

36:11

brushing your tongue, which a lot of people neglect,

36:14

and obviously brushing your teeth a couple of times

36:16

a day as well. And selective

36:19

use of mouthwash can be suitable as well.

36:21

And this is where the nuance is. If

36:25

you're constantly using mouthwash

36:27

on a regular basis, what has

36:29

alcoholic content in it, so the alcoholic

36:31

mouthwash, that can actually be counterproductive

36:34

towards your oral health and your oral

36:37

microbiome because the alcohol can

36:39

wipe out some of the beneficial bacteria,

36:42

which actually produce nitric oxide. And

36:44

nitric oxide contributes towards

36:47

regulating your blood pressure. So, you know,

36:50

you're not going to get high blood pressure by just using

36:52

alcoholic mouthwash, but if you're

36:55

already at risk of high blood pressure

36:58

and you have, you know, a bad oral

37:00

microbiome health, this can contribute

37:03

to poor cardiovascular health as well.

37:05

And it's often noted that people with poor dental

37:08

health and poor oral health have an increased

37:10

risk of heart issues as well. So

37:12

it's, you know, important to keep that in

37:15

good standing. Now, you

37:17

can use mouthwash and mouthwash is not

37:19

going to make your dragon

37:21

breath disappear. It's just going to mask it, but

37:24

you can do things instead of

37:26

mouthwash by flossing and brushing

37:29

your tongue. Now, a lot of the plaque

37:31

that's produced in the biofilm that's produced

37:34

by the bacteria end up on the surface

37:36

of your tongue. And if you don't get rid of that, that

37:38

can contribute to dysbiosis

37:40

and bad oral hygiene. And

37:42

a lot of people don't actually brush their tongue. So

37:45

that is the number one thing that you are probably

37:47

neglecting to do. But for the average person

37:50

regularly using alcoholic mouthwash

37:53

is something that you should not be doing. So

37:56

I posted a recent video on

37:58

my Instagram account showing or

38:00

even commenting on a person

38:03

who's got ascites, which is a buildup of

38:05

fluid inside the abdomen. And this person

38:07

was having an acidic drain, which is

38:09

where the fluid inside the abdomen is

38:12

drained off. Now, usually you can

38:14

get a buildup of ascites, an excess buildup

38:16

of ascites, if you have advanced

38:19

cancers, if you have liver cirrhosis,

38:21

liver failure, if you have really

38:24

horrible infections in your abdomen, all

38:26

of these things can produce a buildup of ascites,

38:29

and it can cause infections,

38:31

trouble with abdominal pain, trouble eating.

38:33

So sometimes it's removed during a procedure

38:35

called a paracentesis. Now, there

38:38

is this myth that you only

38:40

get ascites and you

38:43

only get liver failure if you're

38:45

an alcoholic. Now, liver disease

38:47

does not just happen with alcohol

38:50

abuse and excess alcohol. There is

38:52

a wide range of causes of various

38:56

infections, cancers, autoimmune

38:58

conditions, genetic conditions,

39:01

which can cause liver failure and they have nothing

39:03

to do with alcohol. You have non-alcoholic

39:06

staatohepatosis, it's called NASH. So

39:08

that's non-alcoholic fatty liver disease

39:11

that can happen in people. You can get

39:14

cancers of the liver, you can get parasitic

39:16

infections of the liver, you

39:18

can get metastasis, so

39:21

cancers from another area, which is then spread

39:23

to the liver. So common thing I

39:25

see and I deal with is a cancer

39:27

that's spread from the bowel to the liver, a

39:30

colorectal liver metastasis.

39:32

So there's a bunch of things which

39:35

can cause liver damage and liver failure,

39:37

which have nothing to do with alcohol. And this is

39:39

often a problem that I see and I have

39:42

heard firsthand from patients is that

39:45

they have some liver complications or some

39:47

degree of liver cirrhosis and liver failure, and

39:49

they feel that they're often judged

39:52

based on the history that they just got

39:55

liver problems and people think and they associate

39:58

bad liver equals this person's ability.

39:59

drink alcohol. It's not the case.

40:05

Just before we go, we have Crowd

40:07

Science. It's your turn to ask me a question.

40:09

And this week we've got Emily from Birmingham

40:12

who asked the question, I've been advised

40:14

by a medical practitioner that the only

40:17

way to truly be healthy is to base

40:19

my diet on my blood type,

40:21

my blood group. I'm a vegan for

40:23

ethical reasons. What are your thoughts

40:25

on this type of diet as an NHS

40:28

doctor? Oh, damn, here we go.

40:30

Blood type diet. So

40:32

I'm going to give you the long version and then

40:34

the short version. So it all started

40:37

in 1996 when a naturopath

40:39

who is not a medical doctor called

40:41

Peter Dodamo, thoughts that

40:43

you can have a blood type diet. So according

40:46

to your blood type, whether you're O, A, B,

40:48

A or B, you can have a

40:50

diet that's specific to your blood type that

40:52

will help you lose weight and process

40:54

food more efficiently and generally

40:56

be healthier. And for some

40:59

unknown reason, this crazy

41:01

blood type diet got millions

41:04

and millions of people on this type of thing. And there

41:06

was even recent BBC documentaries

41:08

on the blood type diet and books

41:11

on the blood type diet. There's probably people

41:13

selling courses on the blood type diet and

41:15

even selling supplements to do with that

41:17

stuff as well. And certainly the

41:19

blood is involved in your diet

41:22

and the digestion of food. When you eat

41:24

food, it obviously transits through

41:26

the intestines. The nutrients

41:29

from the food are then transported

41:32

by the blood to various cells and

41:34

organs in the body. That bit is

41:36

legit and that is just science. That is physiology,

41:39

normal human physiology. But the

41:42

individual blood type has no bearing

41:44

on our health when it comes to our diet

41:47

in any way. That is pure pseudoscience

41:49

and not biology. And there is zero

41:52

evidence in the literature, zero zip

41:55

zilch nada that the different

41:57

macronutrients, the glucose, the fatty. acids,

42:00

the amino acids, react to your blood type

42:03

in any discernible way. So

42:05

this is an absolute myth and anyone who

42:07

prescribes you a blood type diet

42:09

is either not a doctor and if they

42:11

are a doctor,

42:12

they shouldn't be. Okay, I hope that answer

42:14

helped Emily and I'm going to tease you with

42:16

another question, the answer to which I'll

42:19

be releasing on Crowd Science Extra,

42:21

another segment of the show dedicated

42:24

just to answering your questions. And

42:26

Leslie from Argyll and Butte in West

42:28

Scotland has asked the question, hi, is

42:30

a large stomach apron always

42:32

due to being overweight? No matter how much

42:35

exercise I do or dietary changes

42:37

I make, I cannot seem to reduce

42:39

it. I'll be going into detail on this question

42:41

from Leslie and more questions

42:43

in Crowd Science Extra. We'll

42:45

still be answering questions in our regular show but

42:47

if you want more, you'll get more.

42:50

The first two episodes of Crowd Science

42:52

Extra are available right now.

42:54

Just visit the referral show page on Apple

42:56

Podcast and hit try free at the top of

42:58

the page to start your free trial today.

43:01

You'll then unlock the extra episodes which sit

43:03

right under this one on the feed.

43:05

Thanks for listening to this episode of The

43:07

Referral. If you love this episode and

43:09

loved learning more about your health, you're

43:11

going to love the rest of the episodes. So hit

43:13

the follow button so you can tune in every

43:16

week. And if you love it, you

43:18

got to leave a review five star all the way.

43:20

And yes, I am a real doctor but it's important

43:23

to know that if you require specific medical

43:25

advice, you need to contact your own

43:27

doctor or your emergency services

43:30

if it's something super urgent. Please

43:32

remember that nothing on this show is

43:34

intended to

43:35

provide or replace specific

43:37

medical advice to you that you would