The History of MTF GRS

Neocolporrhaphy or Vaginoplasty remains the definitive Male-to-female GRS procedure and is the cornerstone of Dr. Bowers’ claim to fame. Historically, the procedure was first performed on Lili Elbe, allegedly the world’s first MTF Vaginoplasty. Ms. Elbe, the young stage performer and poet, ultimately died of complication related to her surgical sex change. The surgery itself, described more as an orchiectomy and penectomy (removal of testicles and penis), was no doubt an overt failure yet opened the door for later pioneers to follow.

Ms. Elbe’s surgery was executed in, ironically, Nazi Berlin in 1933 and was the culmination of two decades of Transgender research in Berlin, the effective birthplace of the modern Transgender movement. Drs. Steinach and Hirschfeld began transgender research in Berlin in the early 1910’s, experimenting with animal castration, gonadal transplantation and elucidation of the chemical composition of sex hormones. Their early research enabled the eventual discovery of DES, the world’s first synthetic estrogen. Following Hitler’s selective destruction of Dr. Hirschfeld’s research laboratory early in 1933, just 3 months after Hitler was installed as German Chancellor, a young Psychiatrist by the name of Harry Benjamin immigrated to the US. A product of Dr. Hirschfeld’s laboratory, Dr. Benjamin established the world’s first clinical psychiatric clinic compassionately attuned to the medical and psychological needs of early Transsexuals in their bid for gender identity. Dr. Benjamin practiced until his 104th birthday, celebrated in early 1999. Dr. Benjamin’s namesake was lent to the naming of the World’s First Professional Organization for the treatment of Gender Dysphoria (so-called HBIGDA, now WPATH). Just as Transgender pioneers throwing high heels in New York City’s Stonewall fueled the rise of the Gay and lesbian revolts of the 1970’s, so too Transgender victims of Hitler’s Pink Triangle nazi designation were instrumental in raising the consciousness and visibility for 20th century transgenders.

Christine Jorgensen made waves in 1952 as the former Navy Serviceman sought sex reassignment in Copenhagen. Headlines stating “Former GI becomes Blonde Beauty” highlighted what was to become the leading ‘news story’ of 1952 as sensationalism sent sex changes to center stage for the first time. Ms. Jorgensen used her notoriety for years as an on stage headliner, eventually succumbing to cancer in 1989 at the age of 62.

In 1958, Dr, Georges Burou assumed notoriety as the inventor of the modern Vaginoplasty with his description of the ‘Penile Inversion Technique’ for MTF Sex Reassignment Surgery (SRS). Practicing in the unlikely locale of Casablanca, Dr. Burou, a French born Gynecologist, established the surgical prototype for later procedures adapted across the world and US. Later designated Genital or Gender Reassignment Surgery (GRS) or even Gender Confirming Surgery (GCS), SRS/GRS has evolved over the past 5 decades with ever more attention to female sexual and aesthetic expectations.

During the 1960s, as Dr. Burou flourished in Casablanca, so too many academic institutions across the US adopted clinical programs for the medical and surgical treatment of Gender Identity Disorder (GID). Although an unpopular diagnostic term for transsexuals, GID allowed a definable medical diagnosis which justified medical and surgical intervention. That said, patients were required to follow exceedingly rigid and narrow definitions of acceptable gender roles in their respective quests for legitimacy. Programs offering SRS included Johns Hopkins, the Universities of Minnesota, Washington, Virginia at Norfolk, Texas at Galveston, UCLA and many others. Despite variable surgical results and restrictive selection criteria, programs were at least available. Then, in 1971, Dr. Paul McHugh was hired at Johns Hopkins University. Among his duties, Dr. McHugh, a Psychiatrist, was assigned to study the psychological effects of SRS on its subjects. Seemingly un fait accompli, that study allegedly showed that TG individuals post-surgery were no happier and possibly more suicide-prone than patients prior to surgery. The argument was further extended by naysayers claiming surgery was an ‘inappropriate treatment for a psychological condition’ despite empiric and anecdotal evidence strongly to the contrary. Johns Hopkins expeditiously closed its doors to the transgender community and most university programs followed suit. This left TG persons with few alternatives.

Dr. Stanley Biber

Few alternatives, that is, until Dr. Stanley Biber’s name floated from mouth-to-mouth, lip-to-lip, alleyway by alleyway along the path of the transgender community. He was the guy, the one who could fix what nature had made wrong. ‘Doc’, he was called. Lacking fax machines, cellular devices, computers, answering machines or seemingly any device of modernity, Doc practiced as a true country doctor in tiny Trinidad, Colorado, performing hysterectomies, gall bladder operations, setting fractures and delivering babies. But in 1969, a single decision changed the course of history when a local social worker walked into Doc Biber’s office and asked if he would do her operation. “Sure!” doc replied, without hesitation, not questioning the nature of the operation. When the patient revealed her ‘secret’, Doc Biber, unflinching, simply requested the original surgical drawings for Sex reassignment from Johns Hopkins and made plans for the Operating Room. After all, if America could go to the moon, which the US did in July of that same year, Doc Biber could surely change someone’s sex. And so he did! Again and again and again. Again, that is, until a local Trinidad doc complained about these ‘sex changes’ being performed in a Catholic Hospital. Once again, unphased, Doc Biber wrote to the Vatican, explained the nature of Gender Identity Disorder, as it was called, a medical condition worthy of intervention. Shortly thereafter, Doc received word from Rome that the Pontiff, Pope Paul VI, had signed off on his surgical care for transgender persons there in Trinidad, Colorado. Mt. San Rafael eventually left its Jesuit roots as it became a community hospital and modernized in the early 1970’s. But by then, Dr. Biber’s reputation had grown, as his success combined with the serial University closings solidified his reputation and legacy forever.

Drs Biber and Bowers Scrubbing

Dr. Marci Bowers

A later generation of surgeons came along but always found their way to Trinidad sometime during the course of their education: among them, Drs. Schrang, Meltzer and, eventually, Dr. Marci Bowers. Marci arrived in 2003, after first visiting Trinidad in 2000. Dr. Bowers was the first transgender woman* to attempt and master the surgery after many years practicing as a Gyn Surgeon and Obstetrician in Seattle. As Dr. Biber said shortly after her arrival, ‘Many have come to Trinidad. Some did not have the courage, some did not have the heart and some did not have the hands. Marci is the first to have all three’. Adding to the fascination of her arrival was the fact that both Dr. Biber and Marci’s mother shared a birthday, May 4 and that both Doc and Marci completed their very first sex reassignment at exactly the same age (45).

Doc Biber continued to practice general family medicine out of the same office after Marci’s arrival. Unapologetic in its charm, Doc’s reception area became the stuff of legend with its fading, cracked linoleum Caduceus flooring, weathered bullfight posters and array of upholstered metal chairs and loungers circumscribing the room. For an apt description, read ‘Transister Radio’ by Chris Bojolian.

“My first visit to Doc’s office shortly after arriving in January 2003 was interrupted by a loud, high-pitched call out from his secretary, Marie, beehive hairdo seemingly lifted from 1969, still perfectly coiffed above her petite but aging face and shoulders. After announcing, ‘Tranny on line 2’, Marie, who birthed one of Dr. Biber’s 9 children, seemed slightly embarrassed after realizing that I was within earshot of her pronouncement, suddenly awakening, it seemed, to the notion of political incorrectness in her choice of words. Doctor Biber, steadfast in his defense of transgender surgery, remained on the Hospital Board until his death in January 2006.

The move to California

“Following Doc’s death, the mood on the Board and sentiment in the community began to change ever so slightly. Sensitive to these changes, I always knew that there may come a time when I must go. Unthinkable as it may have been, leaving Trinidad became a reality shortly thereafter. Having weathered the threat of massive increases in price to patients**, most of whom still paid completely out-of-pocket, any subtle shift could become grounds for my departure. And I wanted that departure to be entirely on my terms. So in 2010, when I felt my voice and the unique needs of my patients being ignored, I pleaded with Karl Gabrielson, then Chairman of the Hospital Board and President of Canyon Builders. I did not want to leave Trinidad so invoked the words and ideals of Dr. Biber in my plea. Mr. Gabrielson, whose imploding Jack Nicklaus Golf Course community was said to be levying partial blame for its failure upon the Transgender issue in Trinidad, appeared to genuinely listen to me. How this regular string of Transgender patients and their families had negatively impacted out-of-towners’ choice of where to play golf was never explained to me. Nonetheless, when confronted with my impassioned words of warning, Karl responded with ‘well I guess Dr. Biber is dead now, isn’t he?’ My jaw dropped. Sitting uncomfortably inside What A Grind Coffee Shop, I knew in that moment that it was time to leave Trinidad, the once and mighty ‘Sex Change Capital of the World’.”


*Apologies to Sheila Kirk, MD, a trans woman, who performed a handful of MTF sex changes while at the University of Pittsburgh during the mid-1990’s and served on the Board of Directors of HBIGDA (now WPATH)
**Rich Armentrout, then newly installed Chief Financial Officer at Mt. San Rafael Hospital and Jim Robertson, CEO, chose Pearl Harbor Day 2009 to announce to Dr. Bowers that hospital fees for Sex reassignment would rise from $11,500 to a gradual peak of $40,000 per patient within 12 months. Rich, a graduate of Bob Jones University, had earlier publically proclaimed to his Christian congregation in Trinidad that God had ‘brought me to Trinidad to get rid of that sex change surgery’. Plans for the massive fee increases were abandoned shortly after Rich had been relieved of his duties there at Mt. San Rafael Hospital for allegedly leaving a loaded handgun on the toilet paper dispenser in the hospital lobby men’s room. The .357 Magnum was discovered by an 8 year old boy who turned it in, un-discharged, to local authorities.

History II

The modern history of GRS includes surgeons who have come on the scene during the past ten years. Interestingly, this club is rather small and bears an important indication of who performs what and where the best surgery is being performed. The prototype so-called Penile Inversion technique for MTF vaginoplasty was originated by French Gynecologist, Georges Burou. Dr. Burou practiced in Casablanca, Morocco from the 1950’s until the early 1970’s. Dr. Burou’s technique, as I know it, was adopted by the Johns Hopkins gender services program until an ill-fated study authored by Dr. Paul McHugh in 1971 purported to show that Transsexual women were less happy after surgery than before. This, despite the fact that the results did not support this conclusion. Nonetheless, Johns Hopkins closed its doors to transsexuals and Dr. Biber stepped into the void left by Johns Hopkins and other university programs around the US who followed suit. As the 20th century rolled on, Dr. Biber became the mainstay of this movement. Dr. Biber believed passionately in the validity of the gender transition process, eventually becoming one of HBIGDA’s founding members.

The Second Wave
As the transgender movement slowly ambled forward, new physicians expressed interest in the field. In the US, these surgeons included Dr. Eugene Schrang and Dr. Toby Meltzer, both plastic surgeons. Each spent time observing Dr. Biber, adopting his protocols and then modifying the technique, predicated by their own standards and experience. In Montreal, Dr. Yvan Menard and later, Dr. Pierre Brassard arrived on the scene but adopted a single stage approach to MTF vaginoplasty. Dr. Bowers, who first met Dr. Biber in may 2000, left her practice to join Dr. Biber in January 2003. Primarily on the basis of age, Dr. Biber was unable to retain malpractice insurance beyond age 80, thereby foreshortening the apprenticeship of Dr. Bowers. She realized, however, that Dr. Biber’s technique, reproducible as it was, needed modernization. She approached US surgeons but was rebuffed. Fearing competition, some said, these surgeons were unwilling to educate Dr. Bowers or share their experience. Fortunately, Dr. Brassard offered gracious tutelage. Dr. Bowers has gone on to share her knowledge and techniques with many surgeons from around the world. Her training of Osteopathic Plastic Surgery Director Sherman Leis allowed residency education for a new generation of transgender surgeons including Drs. Christine McGinn, Charles Garramone and Kathy Rumer. Dr. Bowers has also carried her knowledge overseas to the country of Israel. Visitors to her practice include surgeons from Australia, China, Mexico, Brazil, Belgium and Serbia, among others.