GRS Technique

Where can I find a therapist? Primary care doctor?

Robin maintains an active data base of mental Health professionals and primary care physicians/providers. Most medium to large size cities across the US now have trans friendly professionals who can assist in either mental health support or for patients needing general care prior to and after surgery.

What makes Dr. Bowers’ vaginoplasty procedure different from surgeons in Thailand? Elsewhere?

For one, Dr. Bowers has been through the experience. She knows how important this procedure is to you. Secondly, Dr. Bowers is a gynecologist, still, the only gyn in the world who performs GRS. She knows what she is seeking in surgery, visually and functionally. Finally, her One-stage procedure utilizes tissue that is a) sensory, b) secretory, c) pink (a critical detail for anyone of color!), and d) non-hair bearing— to line the inner labia. Embryologically, this mucosal tissue is derived from what did line the inner labia when all fetuses are female. To discard this critical tissue, as is done in Thailand and in two-stage procedures, is not what happens in nature and does not look truly natal. For example, hair should never grow between the labia minora! Quite simply, the procedure we perform is most compatible with the normal developmental process had the MTF been born female. Anything less embodies a dinosaur technique that the world is slowly abandoning.

Why is a one-staqe technique better than a 2-stage technique?

Dr. Biber and many of my predecessors utilized a 2-stage procedure: The first stage was for function and the second was to improve cosmetics and define the labia and clitoral hood. The only way to achieve both of these goals in a single surgery is to utilize the beautiful, pinkish mucosa of the urethra that 2-stage and Thai surgeons currently discard. A second stage is always available for our patients as well although the cost and recovery from this second operation is only rarely necessary. Under 50 patients in more than 1200 GRS operations have needed a second cosmetic procedure to complete their GRS with us.

Does Dr. Bowers remove the prostate?

No, in the standard GRS procedure, all surgeons dissect through the lower aspect of the atrophied prostate in creating a vaginal cavity. Prostate removal is not necessary. If the prostate does need examination in the future, this should be done via the vagina, not the rectum as the prostate lies in front of the vagina. On estrogens, the prostate atrophy is so striking that we am not aware of any true de novo case of prostate cancer arising in a post-op woman on HRT.

Patients are talking about the ‘B-spot’  — is this the same as the G-spot in natal women?

Yes, the B-spot, as some have called this area of the body is exactly analogous to the G-spot in natal women. Basically, it is the erectile tissue that is placed internally and along the inner labial lining. It is essentially an extension of the undersurface of the penis, which contains the urethra. Many men find this a source of arousal –pre-operatively and indeed, the area is preserved in Dr. Bowers’ technique, allowing for a more meaningful sexual feeling after vaginoplasty. The area can be accessed just inside the vagina along the front wall beneath the bladder , particularly with penetration.

Does Dr. Bowers offer surgery for adolescent MTF’s?

A: Yes, Dr. Bowers had long believed that completing vaginoplasty for adolescents is a reasonable and responsible decision. We do weigh many factors, not the least of which are family’s pleas for surgery. Because surgery does come with responsibility, we look for individuals with demonstrated maturity and full familial support. In this stable home environment, I believe—as do many others— that completing a full transition while in High school allows the MTF child the chance to fully integrate before entering adulthood and/or college. I cannot think of a more difficult challenge than to insist that a kid wait until age 18, operate and then send them off to the myriad challenges of college. This is a prescription for disaster or disappointment. Complete the transition in the senior year, stabilize, integrate, then enter college. Adolescent surgery does require additional precaution including a family consult (parents and child) and special approval from Mills-Peninsula credentialing well prior to surgery.

Pre-op Hormonal Treatment Guidelines

It is recommended that all patients follow the WPATH SOC. That said, there are widely varying routines and pathways towards gender transition. Guidelines should not  be punitive (for those who in the past may have self-prescribed or acquired HRT through black market sources) but general guidelines that attract patients back to more standard medical regimes and followup. Hormones, it must be emphasized, are incredibly safe. Extensive bloodwork and testing is NOT necessary, despite small theoretic risks of ongoing HRT. Baseline labs including general chemistries, lipid profile, electrolytes and liver and kidney function are reasonable. Hormone levels are useful—but not often—particularly when the effectiveness of the hormone regimen is in question (e.g., minimal breast growth in women or failure to deepen the voice or grow facial hair in guys) or on an annual basis or as symptoms permit. Blood pressure and progress of the hormonal affects should be followed and documented throughout treatment.
Our practice in particular favors bioidentical hormone regimens. Bioidentical means that the hormones themselves are identical to those that are produced naturally within the human ovary or testis. The route of administration is also important in determining biological effectiveness in the patient and should be considered strongly when prescribing. Although oral preparation of hormones tend to be less costly, this route of administration can be effected by intestinal absorption and metabolism to other compounds within the liver before the body has ever benefited from the hormone itself. These metabolites themselves can have medical and hormonal effects as well but are not necessarily as potent as the parent hormone. Injectable (shots!), sublingual (“below the tongue”), or transdermal (“across the skin”) routes have a more direct access for the hormones to enter the blood stream without the metabolic considerations but are usually more expensive and challenging to manage.
Prior to initiating HRT, it is recommended that patients first sign a “hormone consent form”.  The consent is an acknowledgment that hormones have both irreversible and reversible effects, deleterious effects on fertility, variable effects on libido (men go up, women go down—surprise!!), and major body changes. But, hormones are also limited in what they can do and they alone will not make you the man or woman you hope to become.They also have slight risks and come with patient responsibilities ( like visiting your doctor :)) It is also assumed in the consent process that you have initiated some adjunctive psychotherapy in whatever form that may look like for you. We want a proper diagnosis and psychotherapy can have tremendous benefit as you go through the process (hey, we all need an ally).
When starting hormones for our MTF patients, we recommend 2-4mg per day of Estradiol per day, along with 100-200mg of Spironolactone BID, with divided dosing.  Your physician is welcome to call us with questions!
Here are some links where you can learn more:


How does Estrogen Therapy affect sperm count in the pre- surgical MTF

Anecdotally, there are reports (and I know someone first hand) who, thinking they were on HRT could not impregenate—generally true but not fool proof—did conceive a normal, healthy child. Normally, after introducing estrogen to transition inducing levels, sperm production drops to near zero if not zero—by 3 months for sure. But estrogens per se are not adequate birth control.

Occassionally, patients wish to regain fertility by discontinuuing HRT in order to store sperm or whatever. If so, this can take up to 6 months to regain but generally does return to some degree. Ability to gain and maintain an erection, however, is often lost or limited, ragardless of discontinuation. Orgasm, on the other hand, with stimulus in its many forms, is achievable (just as for women and those whom are post op!).

How do I decide which surgeon to choose?

Referral by a close friend or someone you trust is still the time-honored best bet as to getting reliable information. The internet has great information but is often misleading. Blogs or personal accounts by a patient against a particular physician can be useful when the information is corroborated or becomes a pattern but is often generated by someone frustrated, with time on their hands, who is unable to let go. Transgender surgery is amazing but inherently limited in its scope. Physician websites are also helpful but a word of advice here—caution. Particularly on the results pages, physicians often post altered photos or photos that are angled such that details that are unflattering to the physician are omitted. If a surgeon posts photo results that show patients with legs closed (as several docs do, amazingly enough!!), RUN! This surgeon is, by definition, hiding scars or true results. Ask numbers—if surgeons only perform a handful of male-to-female vaginoplasties occasionally, this is a red flag. Vaginoplasty is surgery that is highly artistic and unique to that surgeon—it is NOT cookie cutter, run-of-the-mill surgery. Be wise! Better to wait and spend good money than to scrimp, rush or choose hastily. When in doubt, come to us. When you look further until your eyes are sore, come to us. And finally, be wary of a surgeon who offers a seemingly endless variety of surgeries. From FFS to vaginoplasty to Hair restoration, if this doesn’t spell jack-of-all-trades-master-of-none, I don’t know what does. Surgeons, when successful, narrow their surgical offerings. They limit and perfect that which they are best known for.

Has Dr. Bowers considered the use of buccal mucosa to line the neovagina?

Yes, Dr. Bowers is always considering new ideas and technical improvements to her procedure. The buccal mucosa lining, however, is not something that she will be adopting. Most who report use of the buccal mucosa do so in women who were congenitally born without a vagina and lack a suitable source of graftable material anything akin to the scrotum that is used in our procedure. Also, the buccal mucosa, although secretory (mucous producing), is not analogous to the natal vagina. At best, strips of the purple-appearing buccal mucosa are grafted to the neovagina. There is not nearly enough buccal mucosa (mouth lining) to line the entire vagina. The scant mucous that is produced, differs markedly from that produced as a transudate across the vaginal walls in natal females. Visual and tactile differences in the quality of the vaginal lining are also substantial compared to the well-established use of grafted scrotal skin which retains the closest similarity to natal vagina.

How important is hair removal prior to GRS?

At surgery, the hair follicles are scraped and exposed. We follow with intra-op electrolysis that eliminates 95% of the remaining hair follicles. 3 prior sessions of laser or 5 sessions of electrolysis completed at least 3 weeks prior to GRS should allow us to eliminate virtually all of these hairs. We virtually never hear of hair in the vagina being a problem. 30% of patients remove no hair whatsoever prior to GRS and still do not complain of hairy vaginas, thanks to the thorough clearing we do in surgery.

Do I need to discontinue my hormones prior to GRS?

The time-honored dogma for patients undergoing vaginoplasty is that estrogens increase the risk for blood clots and that all hormones must be discontinued. This suspension of hormones leaves patients moody, depressed, achy and overall not feeling well around the time of surgery. On the other hand, we do not stop hormones or birth control pills in natal women undergoing gynecologic surgery. My feeling is that those same rules can apply for our patient population so long as we drop doses as low as possible. Such has been our philosophy since 2003 without incident. We do not interfere with those who have already discontinued their HRT on the advice of their home physicians or specialists. Dropping the dose as low as possible 4 weeks prior to surgery is our current advice except in patients with higher risk.

Will I need a labiaplasty after GRS with Dr. Bowers?

Just 40 patients in 1100 GRS have returned for labiaplasty. That said, a second surgical procedure can help the overall cosmetic results of any surgery performed anywhere. A labiaplasty was always performed— and still is—by 2-stage surgeons. Personally, I love to perform labiaplasty as it allows me and patients to interact, decide what is important and collaborate on a creative improvement to what was created by the first surgeon.Frequently Asked Questions: Hospital stay

Are family members allowed to stay with me in the hospital?

Yes! Mills-Peninsula allows visitors during regular visiting hours (8 AM-8 PM) but does allow a single friend or family member to remain in the room with our patients. You will be allowed to sleep in the room in a window seat type bed—not exactly Ritz-Carlton accommodations but adequate for most.

How convenient is it to find Dr. Bowers office/Hospital?

As of March 2013, we will be in our new office location at 345 Lorton Avenue, Suite 101, Burlingame, CA. This will put both Mills-Peninsula Hospital and our office within 10 minutes of SFO by car/taxi.

What are my transportation options while in the Bay Area?

If coming from out of town, you will be met at baggage claim by our driver from Dash Sedan and Limousine service. They will take you to your hotel and will pick you up once again from your hotel following your stay with us. Dash will only pick up from SFO, however. There is no limit on number of guests. Taxi service with Burlingame Taxi Service (650-245-0389), Luxor Cab (650-344-1455), and Broadway Taxi Cab (650-200-6378 are options for getting to and from Dr. Bowers’ office and the Hospital. There are also numerous quality rental car options in Burlingame if you do not wish to rent at the airport.

Does Mills-Peninsula have wi-fi?

Yes, absolutely.

How is the food at Mills-Peninsula?

The hospital kitchen actually has a chef. The menu is completely a la carte and unlimited. Not that our hospital food is gourmet but, as hospital food goes, it is very good.

Will the hospital staff be sensitive to my needs?

Dr. Bowers has worked very hard to gain the respect of the staff—it shows. The staff like us and we like and appreciate them. They adore working with our patients and, with rare exception, will treat you with kindness. Diversity is our strength—hey, it’s the Bay Area!

When and where will I be discharged?

Patients leave the Hospital on the 3rd post-op day so long as everything is going smoothly. You will need to stay in the area for 3 more nights at which time we will be removing the bladder catheter (Foley) and packing in the office. Also at that time, we will be teaching you dilating and teaching with Michelle. This happens on that 6th day after surgery. At present, we do not have an aftercare facility. This will change soon but, for now, patients are covered for a 3-night stay in either the Staybridge Suites (1350 Huntington Ave., San Bruno 877-859-5095) or the Residence Inn (2000 Winward Way, San Mateo 650-574-4700). Both are rated 4-4.5 on Tripadvisor and include meals (breakfast/dinner) and a kitchenette. Rooms are large enough to accommodate up to 4 guests. You can also choose another local hotel or family/friends if they live close by.

Can I sight see once I am out of the hospital?

Most patients will be shockingly mobile and unlikely to experience complications. However, caution here. A car ride into the city, across the Golden Gate Bridge or out to half Moon Bay is possible but forget about shopping along Market Street, riding any cable cars or finding that must-have trinket in China Town. Dragging a Foley catheter bag through Haight-Ashbury just does not seem cool.

Follow-up and after care

Do I need a gynecologist following GRS or will my primary care doctor be sufficient?

Most primary care docs perform pelvic examinations on their female clientele. The best advice is to continue to see the provider with whom you have had a long and trusting relationship. If specialty care is needed, referrals can be made. Some patients prefer to see a GYN once GRS is completed. GYN’s are generally more comfortable with post-surgical care but seeing a GYN following surgery is not automatic.

When should I see my doctor following surgery?

4 weeks normally, unless problems arise.

What happens if my primary care doctor has questions after seeing me?

Call us, by all means. We are here to help.

Is taking estrogens on a long term basis safe?

This is an ongoing question subject to future research although yes, hormones on a long term basis appear to be safe. 
Our summary of the need for hormones of some sort is as follows: We, as adults, need hormones, either predominantly estrogen (or testosterone). Men and women normally have both. Estrogens provide support for bone, dental and mental health. They also may provide some cardiac protection and do most certainly keep the prostate atrophic (inactive and small). Hormones are also important in maintaining skin integrity and interest in sex.

What if I have problems after GRS? Questions?

For problems, Dr. Bowers and Robin will provide you with their respective cell phone numbers located at the bottom of your discharge instructions prior to departing the hospital. Texting has become our standard method of communicating for each of us due to time constraints. You may also call although this we would ask be in the unlikely event of an emergency. Michelle is also a valuable resource and a great source of reassurance in The Office if you have any concerns during business hours. Problems with dilation, for example, can be handled on a drop-in basis. We normally hear from very few patients following surgery so please! Communicate with us if you have concerns of any kind. We are with you all the way! 911 is always a last resort, of course, but true emergencies are as rare as being paid in pennies, gold coins or Silver Certificates.

Will I be able to orgasm following GRS?

Yes, almost invariably, orgasm will be possible. Patients report orgasm as early as 2 weeks (even though we recommend no sexual activity until after 12!). Regaining the ability to orgasm though is more difficult than advertised. Patience and persistence is the key. The clitoris will probably feel annoyingly sensitive due to its derivation from the head of the penis. Like before, the erectile areas around the clitoris but not the clitoris itself are going to be most important in achieving orgasm as a healthy post op. Orgasm is complicated and for women is normally more challenging. But relax! It’s supposed to be fun!

What if I am unable to achieve orgasm?

Try, try again, by all means. Sometimes it takes friction. Sometimes it takes vibration. Sometimes it takes penetration. Sometimes it takes a combination but it will work. Take comfort in the fact that most of Dr. Biber/Schrang’s patients have been able to orgasm even lacking the dorsal nerves of today’s fully preserved clitorises. Occasionally, testosterone can be added back as a cream in order to lower the orgasmic threshold if orgasm remains difficult. Best of all, as a woman — who cares? Physical contact of any kind trumps all!

When can I resume sexual activity after GRS?

12 weeks although some do get busy earlier. Common sense here. If it feels good, it is probably ok. For receptive intercourse, caution and lots of lubrication is good advice.


I recently inherited a substantial sum of money. Are there charitable organizations that Dr. Bowers recommends?

Yes! And thank you. Depending upon one’s income level, charitable donations, the lifeblood of any non-profit organization, can cost individuals less than .35 on the dollar. Dr. Bowers serves on the national board of directors of GLAAD and TLC (Transgender Law center). She also recommends donations to the Southern Poverty Law Center (anti-hate organization), Lambda Legal and The Jim Collins Foundation (which provides surgery funding for Transgender individuals requiring financial assistance)

My family came to accept me gradually and credited shows like “Sex Change Hospital” for helping them to understand. Will Dr. Bowers be doing any more television shows?

Dr. Bowers has been approached by literally scores of media organizations looking to develop trans programming with her as the lead character. Dr. Bowers though emphasizes her role as physician and surgeon first but is currently planning another upcoming show with the creators of SCH. She also continues to offer expert commentary when asked by news media organizations.