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Frequently Asked Questions (FAQs)

Preparation

Hospital Considerations

Follow-up and After Care

Preparation

Where can I find a therapist? Primary care doctor?

Follow this link to access our database of mental health professionals. Most medium to large sized 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. To find a local provider in your area, visit outcarehealth.org

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 GAV. 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. Embryoloigcally, 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 person AMAB been born female.

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

Dr. Biber and many of Dr. Bowers’ predecessors utilize 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 1800 GAV operations have needed a second cosmetic procedure to complete their GAV with us.

Do Dr. Bowers and Dr. Gunther remove the prostate?

No, in the standard GAV 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 estrogen, the prostate atrophy is so striking that we are not aware of any true de novo cases 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 perform the peritoneal skin grafting technique?

Because Dr. Bowers has a 15% faculty position at Mt. Sinai-Beth Israel since 2016, patients frequently ask if they can avoid the long queue for surgical care in California. In other words, some try to have Dr. Bowers work on them but in newer teaching locales. Indeed, this is possible although it must be realized that Dr. Bowers may not actually be the primary surgeon in the new location. In California, Dr. Bowers is always your surgeon. In the teaching locales, there are other faculty physicians, fellowship doctors, or other trainee doctors who are learning and may be performing portions or all of the surgery. Obviously, teaching is essential if surgical care for transgender patients is to be available globally. Dr. Bowers believes very strongly in this teaching goal and established the first comprehensive transgender surgical teaching fellowship in the world in conjunction with Mt. Sinai-Beth Israel in New York in 2017. Other locations in Denver and Toronto hope to replicate this success and Dr. Bowers will be a part of those initial teaching efforts but likely not an ongoing faculty member except in New York.

If patients do indeed wish to have surgical care in non-California locations where Dr. Bowers will be teaching, you MUST contact the respective gender services programs in your desired location. Keep in mind, pricing may vary substantially in teaching locations, particularly for those paying cash.

Peritoneal lining, skin grafting, and other considerations for younger patients seeking surgical care

Adolescents seeking surgical care but without enough skin for a traditional outcome is an emerging problem as more trans kids on blockers come of age. Not all kids on blockers are prescribed these early enough to prevent genital growth. In fact, many blocked kids do have enough. But, there are many others who simply lack adequate skin when blocked early. Additional options are clearly needed.

To clarify, we do not currently offer surgery on adolescents under 18. – However, an in-person consult is advisable for all patients who have been on blockers since 18 or younger to assess whether there has been enough growth of genital material.

Another significant concern is the ability to orgasm following surgery on younger patients-this is a basic human function and this sense needs to be developed/recruited/embraced BEFORE FINAL SURGERY IS PERFORMED. If a child had never experienced orgasm prior to scheduling GAV, please consult with your endocrinologist as there may be options.

Traditional methods of grafting best use groin skin or lower abdominal skin. New procedures like peritoneal grafting and other sources of vaginal lining are exciting and important but still relatively new-Dr. Bowers does have a fair amount of experience with use of the peritoneal lining and confidence that this will be a major breakthrough. However, Dr. Bowers does all of her innovations with Dr. Jess Ting, Bella Avenassian, and the Gender Services team at Mt. Sinai in New York City, where she has a 15% faculty appointment. However, unlike our California office, all NY cases need to be coordinated with Mt. Sinai. My faculty agreement with them allows me to operate, consult, and teach, but the actual care, payment, and scheduling is via Mt. Sinai.

If you wish to pursue care in New York, please let us know and we will put you in touch with Dr. Ting’s staff for scheduling.
If California is an option, please contact our California office as it is never too early to begin planning with our long queue for surgery in California.

Do Dr. Bowers and Dr. Gunther offer surgery for adolescents AMAB?

Unfortunately, at this time we cannot operate on patients under the age of 18. That being said, we do understand wanting to get surgery completed as soon as possible and we recommend coordinating with our office early, so we can hopefully get patients in by the time they turn 18. In the future, we also hope to add surgical options for younger patients. You’re welcome to call our California office if you have any questions.

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 follow-up. 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 effects 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 affected 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 bloodstream 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 hormoens 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 patients AMAB, we recommend 2-4 mg per day of Estradiol per day, along with 100-200 mg of Spironolactone BID, with divided dosing. Your physician is welcome to call us with questions!

Here are some links where you can learn more:

Callen Lorde Community Health center</span

UCSF Center for Excellence for Transgender Health

WPATH

Tom Waddell Health Center

Mazzoni Center

How does Estrogen Therapy affect sperm count in the pre-surgical candidates AMAB?

Anecdotally, there are reports (and I know someone first hand) who, thinking they were on HRT could not impregenate—generally true but not foolproof—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.

Occasionally, patients wish to regain fertility by discontinuing 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, regardless 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 does prior circumcision affect the outcome of vaginoplasty?

Typically there are no adverse effects of prior circumcision. However, those who are not circumcised do offer surgeons additional material with which to create fuller labia minora. This is a goal of Dr. Bowers and Dr. Gunther and recent efforts may indeed result in some even more realistic outcomes with use of the foreskin.

Do I need to stop hormones prior to vaginoplasty?

This is a question I asked myself shortly after operating on patients in 2003. Cessation of estrogen weeks before surgery was a time-honored mantra that resulted in patients miserable, hot-flushing and unhappy in the days and weeks around the time of surgery. Many had felt that their ‘male’ characteristics had returned. In reviewing literature, it appeared that there was not solid evidence for this anecdotal recommendation. In fact, cis-gender women who I operated routinely while on birth control pills were never asked to stop hormones prior to surgery. Why were we doing this for trans women who were on a far less thrombotic estrogen (estradiol) than that which exists in most birth control pills (ethanol estradiol). As a result, we suspended this policy and allowed patients to take estrogen up until the day of surgery—at a very low maintenance dose (2 mg)— but enough to end hot flushes and misery. The Journal of Urology published our preliminary results in October 2018 after realizing that none of the patients who had been on HRT at the time of surgery had, in fact, experienced any sort of thromboembolic event.

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 2 weeks prior to surgery is our current advice except in patients with higher risk.

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 GAV?

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 GAV 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 GAV and still do not complain of hairy vaginas, thanks to the thorough excision and electrolysis we do in surgery. That said, I do feel that intraoperative damage to the grafted skin as a result of electrical treatment of hair follicles is a possible causes of granulation tissue. As such, it is still highly recommended that some hair clearance be done prior to surgery but not closer than 3 weeks of surgery to allow the skin to recover.

I have a Supprelin implant to block hormones. Can that be removed at the time of my GAV surgery?

Yes, this is a perfect time to remove your implant! Be sure to let us know in advance if you’d like this done so we can pre-auth with insurance. It can be billed with no additional cost to you.

Hospital Considerations

What do I bring to the hospital or surgery center when I have surgery?

GAV

If you are having GAV, gowns, undies, dressings and triple antibiotic ointment will be supplied by the hospital. We provide a quality set of three tapered and graduated stents for dilation- a critical part of your post-operative care.

You may want to bring the following personal care items: a couple of outfits for before and after surgery: a bathrobe, slippers, hair bands, a mirror for your bedside. Consider your favorite lotion, lip balm, and hard candy or throat lozenges as you are likely to be very dry after surgery while on pain medication. You will also need to buy additional lubrication for dilating such as Surgilube or K-Y along with sanitary pads.

If swelling occurs Dr. Bowers may suggest you wear tight-fitting underwear so bring your tightest fitting undies.

We suggest bringing books, music and/or movies to pass the time as you recover. The hospital provides complimentary wi-fi access so laptops and tablets are a good option.

Outpatient Surgery

For those having Outpatient Surgery, bring comfortable clothing to relax at the hotel after surgery. At the time of discharge the Surgery Center will supply ice packs, instruction for your catheter (if applicable) and/or gauze pads (if needed). Discharge instructions and phone numbers for Dr. Bowers will also be provided. You may call or text at any time if you have problems or questions.

If you have any questions about what you will need, review the surgery packet that will be sent to you 2 – 3 months prior to surgery, and feel free to call us!

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’ and Dr. Gunther’s office/Hospital?

We are located 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?

Most hotels offer free shuttles to and from the airport. The Sonesta Suites, for example, offers free shuttle rides twice hourly for anywhere within a 5 mile radius (which conveniently includes Mills-Peninsula Hospital and our clinic on Lorton Avenue). For other transportation, you will need to use a taxi or car service such as Merit Taxi (650) 571-0606, Peninsula Cab (650) 787-3778, and Yellow Cab (650) 342-1234. 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!

Follow-up and after care

What is your current after care facility?

Pending a normal recovery, patients leave the Hospital on the 3rd day after surgery. Patients then stay in the area for 3-4 more nights at a local hotel. A week from the date of surgery, patients return to our clinical office for a post-op appointment where we remove the bladder catheter, the vaginal packing and teach patients how to dilate safely and effectively. Patients are asked to remain in the area for an additional week to monitor recovery and ensure dilations are going smoothly. In total, you can expect to plan to stay in the area for 2-3 weeks. Travel arrangements and housing accommodations are the patient’s responsibility. A hotel we recommend is the Sonesta ES Suites (1350 Huntington Ave., San Bruno 877-859-5095). This hotel is nearby, welcoming and is rated 4-4.5 on Tripadvisor. They also offer our patients a discounted rate. Free Wi-Fi, hot breakfast, on-site parking and a fully equipped kitchen are included. Rooms are large enough to accommodate up to 4 guests. Staying at another local hotel or with family/friends is also a welcome option.

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.

Do I need a gynecologist following GAV 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 GAV 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. 
We are familiar with 2 studies suggesting average long term health for post-ops: Arch Sex Behav. 2005 Dec;34(6):679-90 and Our J Endocrinol. 2011 Apr;164(4):635-42. dog: 10.1530/EJE-10-1038. Epub 2011 Jan 25.

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 GAV? Questions?

For problems, Dr. Bowers and an on-call staff 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 need a labiaplasty after GAV with Dr. Bowers?

Just 40 patients in 1800 GAV 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

Will I be able to orgasm following GAV?

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 GAV?

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.

Miscellaneous

What is a TERF?

TERF is an acronym for Trans Exclusionary Radical Feminist. Janice Raymond is an author from the 1980’s who wrote that transgender women were nothing more than men attempting to enter women’s spaces rather than human beings with feminine gender identity seeking peace with their own bodies. Ms. Raymond would today be considered a TERF. Similarly, JK Rowling wrote a similar fear-based op-ed recently and has been vilified by the trans community accordingly.

What is ROGD?

Rapid Onset Gender Dysphoria is a largely discredited acronym referring to those transgender persons who appear to ‘come out of nowhere’, skeptics attributing their choice to transition as nothing more than social contagion. It is a term used by conservatives and naysayers to deny, discredit and de-legitimize transgender persons and their search for identity as being a short term, impulsive act influenced by others.

What is Autogynophilia?

Autogynophilia is a term popularized by Ann Lawrence and Michael Bailey in the 1990’s attributing sexual attraction to females as a root cause for transition from male to female. A contralateral theory was never suggested for females who identify with a male gender identity. Also troubling is this theory’s heavy reliance on sexual appetite, something most transgender women lack—along with other cisgender women. It has often been said that neither Mr. Bailey nor Ann Lawrence ever lived a woman’s life, attributable to Mr. Bailey’s outlook as a gay man and Ms. Lawrence, a transgender woman who lacked passing privilege.