Preparation (GRS)

Medical History

Please indicate any major medical problems and any previous surgery as well as any current medications.  If you have any heart problems, you must provide a letter of surgical clearance from a cardiologist. You may also be required to provide additional labwork/testing or recent EKG prior to surgery. If you are diabetic, you must provide labwork within 30 days of surgery. Please contact the office if you have heart problems, diabetes, or any other significant medical conditions, within 6 months of surgery to obtain instructions for possible additional medical requirements.

Genital Hair Removal

Hair removal in the genital area is suggested but not mandatory. 5 cycles of electrolysis or 3 sessions of laser hair removal is recommended, completed at least 3 weeks prior to GRS. Intraoperative electrolysis is further performed in surgery. Hair — with this combination — in the vagina is highly unlikely although possible.

The Scrotal Sac (most important): Follicles will be scraped and electrolyzed during surgery, but hair growth cycles prevent us from getting all of the dormant hair.

The Penile Shaft (important):Skin from the penile shaft and mid-scrotum will be utilized in creation for the new vagina.

Thus, these areas are most important to be clear of hair prior to surgery. Remember to plan ahead, you will need multiple hair removal treatments over a 5 – 6 month period (usually 3 – 5 clearings for laser, 5 – 8 for electrolysis) to ensure effective and permanent hair removal. Please stop hair removal treatments at least three weeks prior to your SRS to permit the area to heal and recover.

We’ve come up with a sketch of the recommended areas to remove hair from:














1. From the top portion of the scrotum to just above the perineum, and along the midsection extending to the groin crease.

2. The Penile Shaft.

In general, we recommend laser hair removal. It’s less painful and time-consuming than electrolysis, and our experience is that with the proper laser it is permanent for dark hair with 3 – 4 treatments.

Looking for someone to do the genital hair removal? We’ve compiled a list.


Psychiatric Evaluations

We understand that the World Professional Association for Transgender Health (WPATH) has updated the Standards of Care to Version 7.0.  If you have a specific question about what is  required in your case, please let us know.  Despite our absolute support of the new Standards of Care, nearly all insurance companies still adhere to the requirements below, and your pre-authorization will likely not be successful if you can’t provide the letters of recommendation to their satisfaction.  We continue to pressure insurance companies to update their requirements.

Two (2) Letters of Recommendation must be provided.

Dr. Bowers requires one letter from a PhD or MD therapist/psychiatrist and a second letter from any licensed therapist. Both letters must follow the format outlined in the WPATH Standards of Care, and one letter must be dated within one year of surgery. Specifically, both letters must include the following information:

  • The patient’s general identifying characteristics;
  • The initial and evolving gender, sexual, and other psychiatric diagnoses;
  • The duration of their professional relationship including the type of pyschotherapy or evaluation that the patient underwent;
  • The eligibility criteria that have been met and the mental health professional’s rationale for hormone therapy or surgery;
  • The degree to which the patient has followed the Standards of Care to date and the likelihood of future compliance;
  • Whether the author of the report is part of a gender team;
  • That the sender welcomes a phone call to verify the fact that the mental health professional actually wrote the letter as described in this document.

The readiness and eligibility criteria are outlined below:

The minimum eligibility criteria for various genital surgeries equally apply to biologic males and females seeking genital surgery. They are:

  • Legal age of majority in the patient’s nation;
  • Usually 12 months of continuous hormonal therapy for those without a medical contraindication.
  • 12 months of successful continuous full time real-life experience living as the preferred gender.
  • Periods of returning to the original gender may indicate ambivalence about proceeding and generally should not be used to fulfill this criterion;
  • If required by the mental health professional, regular responsible participation in psychotherapy throughout the real-life experience at a frequency determined jointly by the patient and the mental health professional. Psychotherapy per se is not an absolute eligibility criterion for surgery;
  • Demonstrable knowledge of the cost, required lengths of hospitalizations, likely complications, and post surgical rehabilitation requirements of various surgical approaches;
  • Awareness of different competent surgeons.

The readiness criteria include:

  • Demonstrable progress in consolidating one’s gender identity;
  • Demonstrable progress in dealing with work, family, and interpersonal issues resulting in a significantly better state of mental health; this implies satisfactory control of problems such as sociopathy, substance abuse, psychosis, suicidality, for instance).
  • In general, despite her misgivings about the Standards of Care, Dr. Bowers is required by the hospital and insurers to require two letters of approval (except patients who can document a real life experience of 5 years or more, in which case just one letter is required). Our rigid adherence to a standard of care allows Dr. Bowers to meet insurance requirements and to document our scientific, not impulsive, implementation of surgery. Please be sure your letters of recommendation are received by Dr. Bowers no less than 30 days prior to your surgery date.

Suitability for Surgery

Please note that the final determination indicating acceptance for surgery is made by Dr.Bowers, normally no later than the day prior to surgery. Consultation prior to setting a surgery date is offered, but not required, if you are in the area at a cost of $225.  Skype and phone consults are $175.

Acceptance criteria include:

  • Weight less than 210 pounds (unless height/weight proportional). If you are over 210 pounds (regardless of proportion or level of fitness) you must let Dr. Bowers know in advance; she will contact you to determine if surgery should be postponed. Surgery simply takes longer in heavier patients and puts you at greater risk for complications, If you arrive greater than this weight, you risk postponement, or you will be charged a $750 surcharge to cover the longer length of surgery.
  • Non-smoker (unless specifically exempted by Dr. Bowers). For smokers, tissue healing is truly poorer and the risk of surgical complications greater.

HIV Status

Please send an HIV result from an accredited laboratory performed no sooner than 12 weeks prior to surgery. HIV- Status, however, is not a pre-requisite for acceptance for surgery. (contact Dr. Bowers specifically regarding her criteria).

Skin Grafting

The need for non-scrotal skin grafting to create the neovagina is necessary in no more than 5% of cases. However, this determination does need to be made at the time of the clinical evaluation and is an additional $2,500. Skin from the scrotal sacs is preferred as the graft-donor site and allows us to almost always have enough skin to achieve suitable vaginal length. Grafted skin from the lower abdomen, buttocks, or Repliform® subject to additional fee.

If you do consider yourself to be on the unusually small size, or have specific requirements or expectations for post-surgical depth please include that information in your medical history and consider a consultation with Dr. Bowers.


You will need to arrive in California two-three days prior to surgery with a pre-operative consultation performed at that time. This will need to be arranged with Dr. Bowers’ office. There is no charge for this visit.

Want to schedule surgery? Please use this Application Form when sending in a deposit for SRS.

Already started your countdown? We’ve put together a GRS Checklist for you to make sure you’ve got everything.